1. Leadership for Advancing Chronic Care in Challenging Environments California Chronic Care Learning Communities Initiative Collaboration Kevin Grumbach, MD UCSF and SFGH

2. Institute of Medicine 2001

3. % of People in US with a Chronic Illness 45% 57% 1 Chronic Illness 43% 2 or more Chronic Illnesses Source: C Hoffman et al, JAMA 1996:276:1473

4. Chronic Illness: Prevalence and Health Costs Source: C Hoffman et al, JAMA 1996:276:1473

5. Chronic Illness: Room for Improvement 27% of hypertensives are adequately treated Half of discharged CHF patients are readmitted within 90 days 35% of eligible patients with atrial fibrillation receive warfarin 74% of diabetics have uncontrolled blood pressures, 71% have elevated lipids, and 54% have hemoglobin a1c levels above 7.0

6. R O O M For Improvement: Reprise CHN 30% CHF discharges readmitted within 30 days 21% diabetics have hemoglobin a1c > 9.5% 57% of children with persistent asthma not on inhaled steroids

8. System Problem Needing Systems Solution IOM Redesign Imperatives: –Reengineered care process –Effective use of information technologies –Knowledge and skills management –Development of effective teams –Coordination of care over patient conditions, services, sites of care over time

9. The Chronic Care Model Community Resources Health Care Organization Delivery System Redesign Self-management Support Clinical Information Systems Decision Support

10. Does the Chronic Care Model Work? Impact on quality of care Impact on costs

11. Business Case for Chronic Care Model Depends on payor mix and payment incentives –Uninsured –Global capitation –MediCal –Medicare

12. Other Benefits to the Organization Treating the chronic ills of safety net culture –Activated staff –Culture of improvement and problem solving –Change is possible

13. How can change be created in complex adaptive organizations?

14. Special Challenges for the Safety Net

16. Functional Health Literacy, Diabetic Patients at SFGH Source: D Schillinger et al, JAMA 2002;288:475

20. Assets of the Safety Net $ Incentives not always completely misaligned Systems and organization Talent and commitment

21. The Role of Leadership