1. The Chronic Care Model Mike Hindmarsh Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation
California Chronic Care Learning Communities
Initiative Collaborative
Oakland, CA
November 2-3, 2004
ICIC Website:

2. Three Biggest Worries About Having A Chronic Illness (Age 50 +)
Losing Independence
Being a Burden to Family or Friends
Not Being Able to Afford Needed Medical Care
But what are patients really concerned about?
Source: Partnership for Solutions, Medicare data and Harris polls of Medicare recipients. (from Jerry Anderson)

3. Percent Somewhat or Strongly Disagreeing With Statements
Age Age 65+
Government programs are adequate to meet the needs of people with chronic medical conditions
Health insurance pays for most of services chronically ill people need
People with chronic medical conditions receive adequate medical care
65%
55%
66%
47%
43%
52%
Our view of how well we are doing in providing good health care changes as we age and become more personally acquainted with chronic illness.
Source same as prior slide

4. Number of Chronic Conditions per Medicare Beneficiary
Number of Conditions
Percent of Beneficiaries
Percent of Expenditures 18 1 19 4 2 21 11 3 12 5 7 6 13 7+ 14
Too often we organize our care around a certain chronic condition, like diabetes, or asthma. But the data show a different story. Well over half of those over age 65 have more than one chronic condition and they account for 95% of all health care expenditures.
Source same as prior slide
63%
95%

5. The Growing Burden of Non-communicable Disease
Rapidly aging population
Increased environmental risks—smoking, changed diet, increasing inactivity, air pollution
Double jeopardy: still fighting infectious disease and malnutrition while experiencing impacts of chronic disease
Median age for all regions of the world (except sub-Saharan Africa) will approach age 70 by the year 2030.
Tobacco currently causes 4 million deaths annually in the world, and by 2030 will cause 10 million deaths each year if the rate of tobacco consumption does not decline.
Heart disease is the leading cause of death in every region of the world except sub-Saharan Africa, where HIV/AIDs affects a quarter of the population.
W.H.O. looked at the CCM and adapted it to the developing world.
W.H.O. Innovative Care for Chronic Conditions, 2002

6. Prevalence of chronic conditions
10.3 % have heart disease
23% have HTN
9.1% have asthma
6.2% have diabetes
Prevalence of HTN and diabetes increased in Hispanics and blacks
These data are from people age 18 and over in the US. Now that you see the prevalence, here is some quality data. Of pts with diabetes, 70% reported having a HbA1c in past year and 63% report having a foot exam. These rates are lower among the uninsured. (62% having HbA1c, 48% foot exam, 49% dilated eye exam vs. 64% in the insured population.)
Source: self-report data from 2000 Statistical Brief #5 by Marie N Stagnitti, Medical Expenditure Survey

7. The Burden of Chronic Illness on The Acute Care System
The Average Patient with Diabetes has:
Additional Diagnoses*
45%
Functional Limits**
50%
> 2 Symptoms***
35%
Poor Health Habits
30%
Or you might choose to think about the care of a patients with chronic diseases, such as diabetes.However, don’t fall into a trap. A disease management program aimed only at improving a hemoglobin A1C will miss the mark. These patients often have multiple diagnoses, functional limits and symptoms.
Source: John Wasson, data from howsyourhealth.com
*Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung 17%)
** Physical (31%), pain (28%), emotional (16%), daily activities (16%)
*** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue(23%), foot
(21%), backache (20%)

8. Diabetes Care in the U.S. Harris. Diab Care 2000;23:754-8
Data from medicare patients

9. Use of statins in pts with MI
60% of patients over age 65 with a history of a heart attack were on a cholesterol-lowering medication
33% knew the result of their most recent cholesterol measurement
Sources: Ayanian et al Arch Inter Med 2002;162:1013
Ayanian et al Arch Inter Med 2002;162:1013

10. Hypertension care in US
Over 16,000 patients
27% had hypertension
15-24% had controlled hypertension
27-41% unaware that they had hypertension
25-32% had treated uncontrolled hypertension
17-19% aware of hypertension but it was untreated
15% of Hispanic Americans had uncontrolled HTN, 24% in whites and blacks, more Hispanics unaware of hypertension.
Primarily isolated systolic hypertension
Uncontrolled HTN found in all groups: uninsured, insured, poor, average income
More common among those over 65
Source: Hyman et al NEJM 2001;345: , data from NHANES over age 25.
NEJM 2001;345:

11. Physician treatment practices for hypertension
41% had not heard of JNC guidelines
JNC guidelines recommend treatment to 140/90
43% of MDs would not start therapy unless systolic >160 and 33% would not start treatment unless diastolic >95
Most would choose ACE for first drug
The same researcher asked 723 physicians about hypertension.
JNC=Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure.
Diuretics are generally first line drug.
These are not bad physicians. They are working in a system that doesn’t help them deliver the best care.
Hyman et al Arch Inter Med 2000;160:2281
Hyman et al Arch Inter Med 2000;160:2281

12. The IOM Quality report: A New Health System for the 21st Century
In 2001, the Institute of Medicine published this report. What we have in the US is not a gap between what we know is good care and what we do, it is a chasm.

13. The IOM Quality Report: Selected Quotes
“The current care systems cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”
Here are some quotes from the report.
These are very applicable to Chronic Care

14. Systems are perfectly designed to get the results they achieve
The Watchword
Systems are perfectly designed to get the results they achieve
Source, Don Berwick

15. Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation

16. A Recipe for Improving Outcomes
Evidence-based
Clinical Change
Concepts
System change strategy
System Change
Concepts
We now know it takes knowledge from a wide range of fields to improve care. We’ll be talking about three different kinds of knowledge and put them in a learning model so that we can take it all in.
The first is about clinical care—what the best clinical care is for each condition.
The second is about system design—what do we know about how to design a system so that good care is the outcome.
The third is a strategy to change our current system while we are still working so that it becomes the best system
And we put this all in a strategy to learn them—a learning model, the collaborative.
Learning
Model

17. System Change Concepts Why a Chronic Care Model?
Emphasis on physician, not system, behavior
Characteristics of successful interventions weren’t being categorized usefully
Commonalities across chronic conditions unappreciated.
1) In the past, deficiencies were attributed to bad physicians who just didn’t do the right thing. The emphasis needs to be on the system and the care it delivers.
2) The literature hasn’t been organized in such a way that makes it easy to understand what health care providers were doing and how they were doing it to achieve better results. We need to read the literature and look at who was on the team, what they did, how they interacted with each other and the patient, what visit intervals were like, etc. Clinical trials are more than just one drug vs. another. They create a system of regular, routine care and follow-up, with standardized assessments.
3) Research is primarily condition-specific because of funding sources. We need to be able to provide care in a framework that is similar no matter if the patient has asthma, depression or multiple sclerosis. We need to do this for our own sanity and for our patient’s who can’t be expected to deal with a system where they have 5 case managers, 7 providers and charts in every one of those places.

18. Model Development 1993 -- Initial experience at GHC Literature review
RWJF Chronic Illness Meeting -- Seattle
Review and revision by advisory committee of 40 members (32 active participants)
Interviews with 72 nominated “best practices”, site visits to selected group
Model applied with diabetes, depression, asthma, CHF, CVD, arthritis, and geriatrics
The chronic care model grew in the following way. It began with attempts to improve care for diabetes at Group Health Cooperative, which has approximately 20,000 patients with diabetes. The improvements were based on a careful reading of the literature. In 1996, GHC was funded to bring together international experts in chronic illness care and charged them with finding the commonalities in the ways they provided good care. This seemed like a useful strategy to continue, and RWJF funded a planning grant which had an international advisory committee who did two things: help develop the model and nominate ideal chronic illness care programs. 72 programs were interviewed and the information checked against the developing model. Fifteen of the organizations were site visited. The elements of the successful programs were captured in the chronic care model.
Geriatrics is the interesting area, because care for geriatrics needs to be condition-neutral. Patients have many chronic conditions.
Planning grant published as:
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66
First diabetes collaborative published in:
Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Ave, Suite 1290, Seattle, WA, USA. Jt Comm J Qual Improv Feb;27(2):63-80

19. Clinical Information Systems Self- Management Support
Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
Clinical Information Systems
Self- Management Support
Delivery System
Design
Decision
Support
Prepared,
Proactive
Practice Team
Informed,
Activated
Patient
Productive
Interactions
Our premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.
Improved Outcomes

20. Essential Element of Good Chronic Illness Care
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
The advisory committee told us that good outcomes are the result of productive interactions between an informed, activated patient (and their family or caregivers) and a prepared, proactive practice team. This is what the chasm report calls continuous healing relationship.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66

21. What characterizes a “prepared” practice team?
At the time of the visit, they have the patient
information, decision support, people,
equipment, and time required to deliver
evidence-based clinical management and
self-management support
Let’s look at the two sides of the interaction in more detail.
Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998;11(2):

22. What characterizes a “informed, activated” patient?
Patient understands the disease process,
and realizes his/her role as the daily self manager.
Family and caregivers are engaged in the patient’s
self-management. The provider is viewed
as a guide on the side, not the sage on the stage!
We need to help our patients become more involved in their care. We need to allow for cultural and age cohort variations and personal preference in the amount of involvement. Our interactions need to foster the patient’s sense of control and responsibility.
Anderson R. Patient empowerment and the traditional medical model: A case of irreconcilable differences? Diabetes Care. 1995; March. 18(3):
Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002; November. 288(19):
Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Living a healthy life with chronic conditions. Bull Publishing, Palo Alto, CA. 2000

23. productive interaction?
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
Assessment of self-management skills and confidence as well as clinical status
Tailoring of clinical management by stepped protocol
Collaborative goal-setting and problem-solving resulting in a shared care plan
Active, sustained follow-up
This is how you would know good chronic illness care if you saw it.

24. Clinical Information Systems Self- Management Support
Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
Clinical Information Systems
Self- Management Support
Delivery System
Design
Decision
Support
Prepared,
Proactive
Practice Team
Informed,
Activated
Patient
Productive
Interactions
Our premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.
Improved Outcomes

25. Self-management Support
Emphasize the patient's central role.
Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.
Organize resources to provide support
Self-management support: Empower and prepare patients to manage their health and health care.
1) Emphasize the patient’s central role in managing their health. Providers emphasize the patient's active and central role in managing their illness. (Health care team is only with patients a very brief amt. of time.)
2) Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.
5 A’s is an office-based way to help patients with behavior change.
Assessments include not only knowledge but beliefs and behavior. (Knowledge isn’t enough to change behavior. We need to understand more about what patients value and what they do.)
Advice needs to be given carefully and linked to things that are important to patients. For example, graphing lowered blood sugars after a patient has successful exercised regularly.
Agree on goals that are important to patients. Goals are usually broken down into smaller steps (typically called action plans) that lead to better outcomes.
Assist with problem-solving by identifying barriers, strategies and social or environmental support.
Arrange a specific follow-up plan. Follow-up is not left to chance and can be done in person, over the phone or via , or by using peers and outreach workers.
Review: Effectiveness of SM training for diabetes Norris et al, Diabetes Care 2001;24:561
Glasgow et al in submission
3) Organize internal and community resources to provide ongoing self-management support to patients.

26. Delivery System Design
Define roles and distribute tasks amongst team members.
Use planned interactions to support evidence-based care.
Provide clinical case management services.
Ensure regular follow-up.
Give care that patients understand and that fits their culture
Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support.
Delivery system design is where we all work everyday--(WHO is there and WHAT do they do to contribute to good quality care. This is about HOW we interact with patients.)
1) Sometimes people who work together don’t really work together. We are talking about actually having a team who discusses the work they do and how they are going to do it and how to improve on it. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998;11(2):
2) Planned interactions have an agenda, like a routine physical has a known agenda. These can be either 1:1 or in groups. We can use prompts and tools to help set the agenda and not leave out critical parts of the care. McCulloch et al Effective Clinical Practice 1998;1:12-22 and Disease Management 2000;3(2):75-82
3) Many of the effective chronic disease programs use case or care managers, but many of us in clinic settings don’t have a way to make care managers a part of our team. What we can do is to determine what it is the care managers are doing that improved care, and make those tasks part of our system. We also need to reserve these intensive services for patients who really need them, the complex patients, either because of multiple conditions, complicated treatment routines or for psychosocial reasons. Simon et al. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550
4) Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In real estate, they say, Location, Location, Location. In chronic illness, it is Follow-up, Follow-up, Follow-up.
Support for telephone follow-up: Nurses increase exercise in elderly primary care pts using phone calls: Journal of Geront: Medical Sciences 2002 vol 57A no 11 M733-M740.
Impact of automated phone calls and nurse calls on diabetes in the VA, RCT Piette et al, Diabetes Care 2001;24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction)
5) Give care that patients understand and that fits with their cultural background. This goes beyond providing interpretation but being aware of our values, beliefs and communication style, and adapting to meet patient needs.
Since clinical case management is a hot topic, here is a little more detail about what the evidence shows are effective services.

27. Features of case management
Regularly assess disease control, adherence, and self-management status
Either adjust treatment or communicate need to primary care immediately
Provide self-management support
Provide more intense follow-up
Provide navigation through the health care process
Positive results in multiple trials
Don’t have to have a case manager, but looks like do need to provide these functions in the outpatient setting.
Source for negative review of case management for severe mental disorders: Marshall M et al Cochrane Database Syst Review 2000; (2) CD000050

28. Decision Support
Embed evidence-based guidelines into daily clinical practice.
Integrate specialist expertise and primary care.
Use proven provider education methods.
Share guidelines and information with patients.
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
Many people think that decision support is only about guidelines, but it is much more than that.
Guidelines can be found at
1) We need to not only have guidelines, but get them off the shelf or the computer screen and use them. Make it hard to do it wrong. Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317 Good guidelines describe stepped care.
2) Our typical way of interacting with specialists is to send a patient and hope to get a letter back. We need ways to work more closely together. Some examples are by practice agreements or by sharing team members. Go beyond traditional referral letters to real-time consultation and exchanges. Quinn et al. Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes. Jt Comm J Qual Improv 2001;27:255
Katon et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA Apr 5; 273(13):
3) We know lots of ways that don’t change provider behavior, like lecturing you (which I am doing now. The good news is that a collaborative like you will be working in, has been shown to change the ways systems work and improve outcomes for patients. Providers and care teams benefit from problem or case-based learning, academic detailing, modeling by expert providers.) Wagner EH, et al. Quality improvement in chronic illness care: a collaborative approach.. Jt Comm J Qual Improv Feb;27(2):63-80
4) Another thing we can do is to inform patients of guidelines pertinent to their care. (Sometimes written as “Expectations for Care” to let patient know what their care should be like.) An example is a wallet card for diabetes. This information is designed to encourage patient participation in all aspects of care, from shared decision-making to adjusting treatment according to shared care plans.

29. Clinical Information System
Provide reminders for providers and patients.
Identify relevant patient subpopulations for proactive care.
Facilitate individual patient care planning.
Share information with providers and patients.
Monitor performance of team and system.
Clinical information system: Organize patient and population data to facilitate efficient and effective care.
Many of you may think of this as a registry, but these information systems range from card files to fully functional electronic health records and everything in between. Whatever our system, we need it to perform be able to do these things for us.
1) Provide timely care reminders for providers and patients (Our CIS will prompt reminders to perform needed labs or exams.)
2) Identify relevant patient subpopulations can be identified for proactive care. (Such as to notify all the smokers of a new cessation program, invite patients to a group meeting, or alter medications if some new therapy is shown to be beneficial.)
3) Individual patient care planning is facilitated by the information system. (Care plan is stored and can be adjusted as patient changes their routine and care is adjusted.)
4) Information can be shared with patients and providers. Print outs, care summaries, and communications from distant sites are all ways to increase the efficiency and quality of care we can provide.
5) Monitor performance of practice team and care system—the CIS provides us feedback on how we are doing by provider, clinic or entire system. This feedback loop is valuable information for us to learn from what we are testing and the changes we are trying in our settings.

30. Health Care Organization
Visibly support improvement at all levels, starting with senior leaders.
Promote effective improvement strategies aimed at comprehensive system change.
Encourage open and systematic handling of problems.
Provide incentives based on quality of care.
Develop agreements for care coordination.
Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care.
1)Visible support for leaders is believed to be critical for ongoing success. Ovretveit et al. Quality collaboratives:lessons from research. Qual Saf Health Care 2002;11: Senior leaders provide support by visiting clinical sites, reviewing monthly reports, providing resources and problem-solving for innovators. This support of change in pursuit of better quality care becoes part of the culture of the organization and everyone has a role in quality.
2) Some QI strategies work. Langley and colleagues have categorized what they learned from helping organizations institute improvements. References on Effective QI: Walshe & Freeman Qual Saf Health Care 2002 Mar;11(1): Langley et al: The Improvement Guide, Jossey Bass, 1996
3) Encourage open and systematic handling of errors and quality problems to improve care . Safety has been a rallying cry for inpatient care and is becoming a concern in outpatient care. The system needs to be open and honest about handling errors in care and shortcomings in quality. IOM Quality chasm
4) Examples of provider incentive: Medical Assistance Administration (Medicaid) in Washington state pays for group clinical visits for asthma and diabetes when lead by an MD or ARNP. Includes assessment, treatment planning, group discussion on prevention of exacerbations or complications, proper use of medications and monitoring and living with chronic illness, Q&A, BP, wt, one on one to gather data and review individual treatment plan. Pays ~$20, 4 times/yr.) Reward care teams for quality of care, not just productivity. Not always monetary but through recognition, attending CME. Not just physician providers.
Bonuses for MDs for quality care: employers and health plans starting bonus programs, $ per patient for BP control, lower lipids, blood sugar. Some programs reward establishing a registry, providing pt education and having regular follow-up (Boston Globe 11/7/2002, p A1) Endsley et al FPM March 2004.
5) Develop agreements that facilitate care coordination within and across organizations. Work with local hospitals, VNS, social service agencies in an open and coordinated manner. IOM Quality Chasm

31. Community Resources and Policies
Encourage patients to participate in effective programs.
Form partnerships with community organizations to support or develop programs.
Advocate for policies to improve care.
Community: Mobilize community resources to meet needs of patients.
1) Encourage patients to participate in effective community programs. This means you need to first know what they are. A good example of an effective program based in the community is the Chronic-Disease Self-Management Program developed by Stanford. It is a 6 week scripted curriculum delivered by lay people with chronic illness. Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care, 37(1):5-14, 1999.
Lorig et al. Medical Care 39: , (follow-up data)
2) Form partnerships with community organizations to support and develop interventions that fill gaps in needed services One of the most common partnerships is for safe exercise programs. In the Seattle area, the University of Washington partnered with Group Health Cooperative and Senior Services to make “Lifetime Fitness” exercise program available in senior centers and community meeting rooms throughout the area.
3) Advocate for policies to improve patient care
Another potential way is to have health plans work together. In several states, health plans have coordinated chronic illness guidelines, measures and care resources throughout the community. This makes it much easier for practicing providers to work with more than one plan. (Washington, Oregon, Kansas City)

32. To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change
Interventions focused on guidelines, feedback, and role changes can improve processes
Interventions that address more than one area have more impact
Interventions that are patient-centered change outcomes.
Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G. Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care Aug;24(8):
Evidence that just guideline didn’t change process or outcome in asthma and angina:
Eccles et al BMJ 2002;325:941 computerized guidelines, RCT in UK
Renders et al, Diabetes Care, 2001;24:1821

33. Impact of Planned Care and Collaborative Goal-Setting
Randomized Danish GPs to diabetes intervention groups
Intervention group trained to provide regular goal-setting in periodic structured visits with their diabetic patients
Study team provided guidelines, training, reminders, and regular feedback
Mean HbA1c significantly better years later
Based on Cochrane collab, we would expect this trial to be positive because it covered the elements of successful chronic illness care.
Olivarius N, Beck-Nielsen H., Andreasen A, Horder M., and Pedersen P. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ. 2001, 323(7319):
Olivarius et al. BMJ 10/01

34. Advantages of a General System Change Model
Applicable to most preventive and chronic care issues
Once system changes in place, accommodating new guideline or innovation much easier
Early participants in our collaboratives using it comprehensively

35. Chronic Conditions Collaboratives
Mechanism for spreading health system change via the Chronic Care Model
13 month intensive improvement efforts working with multiple teams from varying health systems
Over 1000 health care systems involved to date
Both national and regional collaboratives
Collaboratives: frailty in the elderly, diabetes, CHF, asthma, depression, arthritis, AIDS, CVD, prevention

36. Regional Collaboratives (past & present)
Washington State: Diabetes I, II, III
Alaska: Diabetes
Oregon: Diabetes, CHF
Chicago: Diabetes
Vermont: Diabetes I, II
New Mexico: Diabetes
Wisconsin: Diabetes I, II
Arkansas: Diabetes
Nevada: Diabetes

37. Regional Collaboratives (cont’d)
Maine: Diabetes
Rhode Island: Diabetes I, II
Arizona: Diabetes
North Carolina: Diabetes
New York: Asthma and Prenatal Care
Indiana Chronic Disease Management Program
New York Health and Hospital: Diabetes & CHF
British Columbia: CHF and Diabetes

38. Successes of Teams in Collaboratives: The Benefit of Organized Chronic Care
times as many patients with major depression will be recovered at six months
Inner city kids with moderate to severe asthma have 13 fewer days per year with symptoms
Readmission rates of patients hospitalized with CHF will be cut nearly in half
HbA1cs, LDLs and BPs are reduced

39. RAND Evaluation questions
Do organizations in a collaborative learning environment change their systems for delivering chronic illness care?
Does implementing the Chronic Care Model improve processes of care and patient health
First, does participating in the collaborative get organizations to change, and if so, did adopting the CCM improve process and outcomes of care? Finally, the sites varied enormously, so what can we learn about the factors that were associated with success.
Lots of back-up material: our surveys, coding methods, design details and some published results are or soon will be available on our part of RAND’s website.

40. RAND Findings Comparing Collaborative Participant Patients with Controls
Decreases in HbA1c for patients with diabetes
Significant increase in patient reports of counseling, education and improved lifestyle for CHF
Significant improvement in QOL for patients with asthma
Significant increase in patients on controller medications

41. Contact us:
thanks