1. Integrating Chronic Care & Business Strategies in the Safety-Net AHRQ Annual Meeting September 9, 2008

2. Chronic Illness in America More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them. Despite annual costs of more than $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care. Gaps in quality care lead to thousands of avoidable deaths each year. Patients and families increasingly recognize the defects in their care.

3. Chronic Care Model Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Improved Outcomes

4. Experience with Collaboratives More than 1,500 different health care organizations and various diseases involved to date HRSA’s Health Disparities Collaboratives- 600+ community and migrant health centers, Academic Medical Centers State, regional, and organization specific

5. Evaluation of Chronic Care Collaboratives RANDHealth Practices can change - organizations made average of 48 changes in 5.8/6 CCM areas Process measures may improve – CHF, asthma, diabetes Outcome measures may improve – better glycemic control in Diabetes Chin, et al. & Landon, et al. May take more than 1 year to see outcome changes Cost-effective

6. Lessons Learned from the Teams Teams spent considerable time searching for/developing tools Some teams felt intimidated by taking on the whole model – asked for a sequence Collaboratives were time & resource intensive Many changes were made in ways that were not sustainable financially

7. Integrating Chronic Care & Business Strategies in the Safety-Net Reaching beyond early adopters Less time- intensive learning Integrate business & clinical changes Provide high- quality tools

8. The Patient-Centered Medical Home and the Chronic Care Model? The NCQA PPC-PCMH view: Much of the PCMH is consistent with the CCM. CCM Patient-centered Medical Home A Common Misunderstanding: The CCM is only a small component of the PCMH. CorrectMisperception

9. The Intervention PLUS Practice Coach _________________ STEP-UP Methodology Toolkit ______________ Business & Clinical Tools

10. Coaching Outline Tasks Assessment Day ½ day presentation on CCM & PDSA On-going meetings by phone, email & in-person Coaching of the leaders & the teams Philosophy Focus on motivation, consultation & education Be mindful of the timing of interventions Fix processes relevant to the task at hand Well-structured & supported groups benefit most

11. Preliminary Reflections Six months is short. Randomization presents both challenges & opportunities. There is a trade-off between customization and collaborative learning, but providing structured learning time is key. Clearly define the coaches role & regularly check expectations.

12. More Preliminary Reflections Identify a leader on-site who is accountable, creative, flexible, & empowered. It is the functions of leadership, not the role that matters. Coaches can identify major infrastructural barriers to improvement. Coaching is one piece within a multi-level system – must seek out alignment between programs. Coaching can jump-start spread.

13. Next Steps Complete evaluation Revise toolkit & make available at AHRQ.gov & improvingchroniccare.org Develop companion Coaching Manual Pursue additional research questions –What are characteristics of teams that can succeed using this toolkit & coaching intervention? –What kinds of micro- and macro- business changes can we expect to see within 6 months or a year implementing the CCM?

14. Thank you! www.improvingchroniccare.org

15. Internal Comparison Arm Baseline Measures Post Measures Our Evaluation Uses A Block-Randomized Design with an External Control Group Intervention Arm Pre-post Changes Secular Trends Baseline Measures Forming Team & Choosing Tools Implementing CCM & related Business Processes Improve. Post Measures Difference in Changes Pre-post Changes Tool Kit + Practice coaching Baseline Measures Post Measures Secular Trends Pre-post Changes External Comparison Arm

16. Measures Implementation: pre-post qualitative interviews –Organizational context & baseline assessment –Plan for change & organizational support –Improvement strategies & implementation processes –Perceived impact & lessons learned Health process & outcomes: HEDIS & utilization Financial measures: ReDeFin –No show rate –# of patient care encounters per FTE –Charges per patient encounter