The Chronic Care Model

Presenter
Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation

Living with chronic illness is like piloting a small plane

To get safely to their destination pilots need:

Flight instruction
Preventive Maintenance Safe Flight Plan

Self-Management Support
Effective Clinical Management Treatment Plan

Air Traffic Control Surveillance

Close Follow-up

Usual care works well if your plane is about to crash

Three Biggest Worries About Having A Chronic Illness (Age 50 +)

1. Losing Independence
2. Being a Burden to Family or Friends 3. Not Being Able to Afford Needed Medical Care

Percent Somewhat or Strongly Disagreeing With Statements

Age 50-64 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% Age 65+ 47%

55%

43%

66%

52%

Number of Chronic Conditions per Medicare Beneficiary

Number of Conditions
0
1 2 3 4 5 6

Percent of Beneficiaries
18
19 21 18 12 7 3

Percent of Expenditures
1
4 11 18 21 18 13

63%

95%

7+

14

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

The IOM Quality report: A New Health System for the 21st Century

http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

The IOM Quality Report: Selected Quotes

The current care systems cannot do the job. Trying harder will not work. Changing care systems will.

IOM Report: Six Aims for Improving Health Systems

Safe - avoids injuries Effective - relies on scientific knowledge Patient-centered - responsive to patient needs, values and preferences Timely - avoids delays Efficient - avoids waste Equitable - quality unrelated to personal characteristics

Recent literature on care

Insert here Recently published literature that demonstrates the gap between what we know and what we do.

Diabetes
69% had HbA1c test in last year
63% had feet checked

64% had dilated eye exam

Among uninsured, only 62% had HbA1c, 48 % a foot exam, 49% an eye exam)

Asthma
48% take prescribed medications
29% report using steroid inhalers

17% report having a peak flow meter at home

Use of statins in pts with MI

60% of patients over age 65 with a history of a heart attack were on a cholesterollowering medication
33% knew the result of their most recent cholesterol measurement

Ayanian et al Arch Inter Med 2002;162:1013

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
NEJM 2001;345:479-486

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
Hyman et al Arch Inter Med 2000;160:2281

Children with asthma

Affects 75 children per 1,000
Disproportionately affects children of low income families, males and blacks over whites

24% of children with asthma miss two or more weeks of school (8% of children without asthma have the same attendance figures.) The healthcare expenditures for a child with asthma are 2.5 times that of a child without asthma.

Diabetes Care in the U.S.

Harris. Diab Care 2000;23:754-8
100% 80% 60% 40% 20% 0%

ot Sh u Fl am Ex e Ey se U SA A 0 13 L< LD 90 0/ 14 P< B <8 1c bA H

The Watchword

Systems are perfectly designed to get the results they achieve

Improving Chronic Illness Care

A national program of the Robert Wood Johnson Foundation
Mission to improve the health of chronically ill patients by helping health plans and provider groups, especially those that serve low income populations, improve their care of the chronically ill.

A Recipe for Improving Outcomes

Model for Improvement
What are we trying to accomplish? How will we know that a change is an improvement?

Evidence-based Clinical Change Concepts

What change can we make that will result in improvement?

Act Study

Plan Do

System change strategy

Participants Select Topic
Identify Change Concepts

System Change Concepts

Prework
P A S D A S P D A S P D

Planning Group

LS 1

LS 2

LS 3
Web-site

Event

Action Period Supports

E-mail Visits Phone Assessments

(12 months time frame)

Senior Leader Reports

Learning Model

System Change Concepts Why a Chronic Care Model?

Emphasis on physician, not system, behavior
Characteristics of successful interventions werent being categorized usefully

Commonalities across chronic conditions unappreciated.

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

Essential Element of Good Chronic Illness Care

Informed, Activated Patient

Productive Interactions

Prepared Practice Team

What characterizes a prepared practice team?

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

What characterizes a informed, activated patient?

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 patients self-management. The provider is viewed as a guide on the side, not the sage on the stage!

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

Chronic Care Model

Community
Resources and Policies SelfManagement Support

Health System
Health Care Organization Delivery System Design

Decision Support

Clinical Information Systems

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Improved Outcomes

Self-management Support
Emphasize the patient's central role.
Use effective self-management support strategies that include assessment, goalsetting, action planning, problem-solving and follow-up. Organize resources to provide support

Delivery System Design

Define roles and distribute tasks amongst team members.
Use planned interactions to support evidencebased care. Provide clinical case management services. Ensure regular follow-up.

Give care that patients understand and that fits their culture

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

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.

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.

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.

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.

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 patientcentered change outcomes.
Renders et al, Diabetes Care, 2001;24:1821

Impact of disease management on control (number of positive trials)

Provider education = 12/32
Provider feedback = 9/23 Provider reminders = 6/14
Weingarten et al BMJ 2002;325:925

Patient education = 24/55

Patient reminders = 6/16 Patient financial incentives =3/4

Features of case management

Regularly assesses disease control, adherence, and self-management status Either adjusts treatment or communicates need to primary care immediately Provides self-management support Provides more intense follow-up Provides navigation through the health care process

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
Olivarius et al. BMJ 10/01

Planning Productive Interactions for Chronic Conditions

For Example: Diabetic Needs Additional Diagnoses* Functional Limits** > 2 Symptoms*** 45% 50% 35%

Not Good Health Habits

30%

*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%)

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

The Growing Burden of Non-communicable Disease Rapidly aging population

Increased environmental riskssmoking, changed diet, increasing inactivity, air pollution Double jeopardy: still fighting infectious disease and malnutrition while experiencing impacts of chronic disease
W.H.O. Innovative Care for Chronic Conditions, 2002

Conmmunity is Critical Source of Care and Support

Applying the CCM to prevention

Similarities:
Require regular attention to behavior change Are population-based Require planned care and active follow-up Use decision guides and occur in primary care Require patient involvement Require provider training Community linkages are helpful

Applying the CCM to prevention

Differences:
Prevention visits are less frequent Changing behaviors to prevent something may be different than when have an illness Prevention may not be as well reimbursed

Benefits of prevention more difficult to perceive

Few people specialize in prevention
Glasgow et al Milbank Quarterly 2001;79:579

Contact us:

www.improvingchroniccare.org

thanks

Congestive Heart Failure -- Rich et al

Community
SelfManagement Support:

Health System: Barnes-Jewish Hospital St. Louis

Decision Support: Guidelines Ongoing consultation with cardiologist Delivery System Design: Nurse case manager Hospital and home visits Telephone F/U Clinical Information Systems

Standardized educational program

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Functional and Clinical Outcomes:

Rich et al, NEJM 1995

Reduce readmission rate Non-significantly lower mortality Increased quality of life

Cooperative Health Care Clinic

Community
SelfManagement Support:

Health System: Kaiser-Permanente Colorado

Clinical Delivery Information System Systems Design: Patient Multidisciplinary Notebook Group Visits

Decision Support: Group Provider Education Peer Interaction Education, Clinical Priorities

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Functional and Clinical Outcomes:

Beck et al, JAGS 1997;45:543

Decreased emergency room use, repeat admits, specialist use Increased calls to nurses, decreased calls to doctors Increased immunizations Increased satisfaction for patient and provider

Health Enhancement Project

Community:
Northshore Senior Center

Health System: GHC and PacifiCare

SelfDecision Management Support: Support: EvidenceIndividual and based Group Interactions Protocols Delivery System Design: GNP visits, peer mentors

Clinical Information Systems: Electronic Chart and Follow-up System

Informed, Activated Patient

Productive Interactions

Prepared, Proactive
GNP reporting to PCP

Functional and Clinical Outcomes:

Leveille et al, JAGS 1998;46:1191

Decreased disability and increased activity levels Decreased hospitalization Increased socialization Decreased psychoactive medication use

The Diabetes Clinical Improvement Roadmap

Health System:

Community

Group Health Cooperative of Puget Sound

Decision Support: Guidelines, Expert Right Track Team, Notebook/Phone Provider Program, Lorig Support Education SelfManagement Support: Delivery Clinical System Information Design: Systems Multidisciplinary On-line Registry, Group Visits, Practice Planned visits, Reports, Retinal Screening Reminders, Program Patient Summaries

Groups

Informed, Activated Patient

McCulloch et al Eff. Clin Prac 1998;1:12, Dis Mgmt 200;3:75

Productive Interactions

Prepared, Proactive Practice Team

Functional and Clinical Outcomes:

Increased retinal, foot and renal screening rates, Increased Hemoglobin A1c testing, Increased proactive/planned care, Reduced costs, Increased satisfaction for patient and provider

Ongoing Depression Treatment

Health System:

Community

12 PCPs in US metro and non-metro)

SelfManagement Support: Clinical Information Systems Pt roster with tx summaries, feedback to care team

Decision Delivery Support: System AHCPR Design: office nurse provided PCP, nurse and guidelines info on treatment office staff all Psychiaoptions, readiness trist review involved. intervention, tx Monthly contact and advice effectiveness with pts by phone on tx adjust assessment via nurse

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Functional and Clinical Outcomes:

Rost et al BMJ 2002;325:934

Incr. Use of antidepressants Incr. Use of counseling 80% remission in 2 yrs (40% for usual care) Higher role functioning

Diabetes Nurse Case Management

Health System:

Community

Prudential Jacksonville
SelfManagement Support: Decision Support: Detailed management algorithms , specialist consult. Delivery Clinical System Information Design: Systems case mgmt. diabetes registry, RN in clinic, patient routine meetings monitoring logs with PCP

1:1 visits with trained RN, follow-up support, pt. Ed class

Informed, Activated Patient

Productive Interactions

Prepared, Proactive Practice Team

Functional and Clinical Outcomes:

Aubert et al Ann Int Med 1998;129:605

decreased HbA1c no increase in adverse events improved self-reported health status

Non-specific Nurse Case Management

Health System
Community
Resources and Policies
developed a guide referred patients SelfManagement Support trained to emphasize patient strengths

Health Care Organization

Regional health system Clinical Information Systems used a nursing documentation program

Delivery System Design intensive case mgmt (home visit every 6 wks, monthly phone calls)

Decision Support no clinical guidelines consult with geriatrician and team

Patient/ Caregiver

Problem-Centered Interactions

Case manager linked to others

Gagnon et al, JAGS 1999; 47:1118-1124

Increased hospitalization No change in functional status

Asthma Resource Center

Health System
Community
Resources and Policies
No links to ER or hosp. Asthma Resource Center in hospital SelfManagement Support Standardized information

Health Care Organization

Regionalized health system (UK) Clinical Information Systems Not described

Delivery System Design Asthma nurse working with practice nurse who runs asthma clinic

Decision Support Thoracic Society Guidelines. Six teaching sessions with nurses

Unmotivated Patient/Family

Ineffective Interactions

Practice Nurse working in isolation

Premaratne et al BMJ 1999;318:1251-1255

No improvement in QOL, ER use or anti-inflammatory use

Stages of Coping with Data

Stage 1: The data are wrong.
Stage 2: The data are right, but its not a problem. Stage 3: The data are right, its a problem, but its not my problem.

Stage 4: The data are right, its a problem, and its my problem.

"Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system."

Donabedian