Teaching the Future for Chronic Disease Management for Family Medicine Residents Anne Sullivan MD Alison Abreu MD University of Iowa Carver College of Medicine Department of Family Medicine

Other members of the Chronic Care Team: George Bergus, MD, MA Ed George Bergus, MD, MA Ed Elizabeth Clark, MD MPH Elizabeth Clark, MD MPH Jo Bowers, MS Jo Bowers, MS Marcia Gaffney, RN CDE Marcia Gaffney, RN CDE Lois Albrecht, MS Lois Albrecht, MS

Objectives: Participants will Identify reasons to teach family medicine residents skills for managing chronic health conditions Identify reasons to teach family medicine residents skills for managing chronic health conditions Learn about how our curriculum was developed and what the components of the UI Family Medicine residency curriculum are Learn about how our curriculum was developed and what the components of the UI Family Medicine residency curriculum are Discuss ways to enhance their own residency program’s curriculum for teaching management of chronic diseases Discuss ways to enhance their own residency program’s curriculum for teaching management of chronic diseases

Before we begin… As you are able, please sit with your legs crossed, left leg on top, until further notice. As you are able, please sit with your legs crossed, left leg on top, until further notice.

Chronic Disease in the U.S. Chronic disease has replaced acute disease as the dominant health problem Chronic disease has replaced acute disease as the dominant health problem Chronic disease is now the principal cause of disability & use of health services Chronic disease is now the principal cause of disability & use of health services Chronic disease consumes 78% of health expenditures Chronic disease consumes 78% of health expenditures Holman H. JAMA Vol 292, No.9, Sept 1, 2004

Suboptimal Care of Chronic Disease Historical focus on the disease rather than person with the disease Historical focus on the disease rather than person with the disease Rushed practitioners not following established practice guidelines Rushed practitioners not following established practice guidelines Lack of care coordination Lack of care coordination Lack of active follow-up to ensure the best outcomes Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses Patients inadequately trained to manage their illnesses Result is reduced compliance with treatment, quality of life and health outcomes

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

Evidence for Chronic Care Model Wagner’s CCM has been shown to improve health outcomes, reduce costs, and/or reduce hospitalizations in a number of chronic diseases, including Wagner’s CCM has been shown to improve health outcomes, reduce costs, and/or reduce hospitalizations in a number of chronic diseases, including HypertensionHypertension DiabetesDiabetes DepressionDepression Congestive heart failureCongestive heart failure Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease

Three-Part Curriculum 1. Knowledge Base 1. Knowledge Base 2. Facilitating Behavior Change 2. Facilitating Behavior Change 3. Outcomes & Assessment 3. Outcomes & Assessment MEETS ACGME COMPENTENCIES MEETS ACGME COMPENTENCIES

Component 1: Knowledge Base Chronic Disease Management in Multidisciplinary Specialty Clinics Chronic Disease Management in Multidisciplinary Specialty Clinics Readings about different aspects of chronic disease care Readings about different aspects of chronic disease care

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Multidisciplinary Clinic Settings FCC Diabetes Clinic, Geriatric Clinic FCC Diabetes Clinic, Geriatric Clinic FCC Coumadin Clinic FCC Coumadin Clinic FCC Depression Care Management Program FCC Depression Care Management Program CHAMPS Cardiac Rehabilitation CHAMPS Cardiac Rehabilitation Physical Therapy Physical Therapy Smoking Cessation Smoking Cessation Pulmonary Rehabilitation Pulmonary Rehabilitation Weight Management Clinic Weight Management Clinic Heart Failure Clinic Heart Failure Clinic Chronic Back Pain Clinic Chronic Back Pain Clinic IMPACT—chronic mental health IMPACT—chronic mental health

Multidisciplinary Clinic Components Clinic Coordinator/Case Manager Clinic Coordinator/Case Manager Multidisciplinary Teams Multidisciplinary Teams Scheduled Visits Scheduled Visits Proactive Treatments and Follow up Proactive Treatments and Follow up Focus on Behavior Change Focus on Behavior Change Systematic Goal Assessment Systematic Goal Assessment Self Management Self Management Group Visits Group Visits

Component 2: Facilitating behavior change Motivational interviewing Motivational interviewing Personal behavior change exercise Personal behavior change exercise Patient self-management Patient self-management

Facilitating Behavior Change Motivational interviewing Motivational interviewing DidacticsDidactics Role playingRole playing Practice in clinical settingPractice in clinical setting Videotape review clinical encounter with a facultyVideotape review clinical encounter with a faculty

Motivational Interviewing An evidence-based method to facilitate change An evidence-based method to facilitate change Collaborative goal setting that preserves patient autonomy Collaborative goal setting that preserves patient autonomy Intrinsic motivation improves likelihood of behavior change Intrinsic motivation improves likelihood of behavior change Facilitate behavior change in the face of denial and resistance Facilitate behavior change in the face of denial and resistance

Behavior Change Exercise 4 week experience 4 week experience Residents keep a log of their diet throughout Residents keep a log of their diet throughout First week: observe diet First week: observe diet Second, third week: assigned dietary modification Second, third week: assigned dietary modification Incorporate 2 features of Mediterranean dietIncorporate 2 features of Mediterranean diet Fourth week: unrestricted diet Fourth week: unrestricted diet

Facilitating Behavior Change Chronic Disease Self Management Program Chronic Disease Self Management Program 6 week course for people living with chronic conditions6 week course for people living with chronic conditions Curriculum incorporates disease management skills, goal setting/action plans, problem solving, communication skills, relaxation, diet, exerciseCurriculum incorporates disease management skills, goal setting/action plans, problem solving, communication skills, relaxation, diet, exercise FM residents participate in groupFM residents participate in group

Self Management Course chronic_support.wmv chronic_support.wmv chronic_support.wmv

Component 3: Outcomes & Assessment Quality improvement project Quality improvement project Care management program for depression, panic disorder Care management program for depression, panic disorder Other interventions Other interventions

Quality Improvement Project Resident begins project during chronic disease block month rotation Resident begins project during chronic disease block month rotation Rotation includes some protected time for project Rotation includes some protected time for project Faculty mentor assigned Faculty mentor assigned

QI Project Resident selects a project, e.g. Resident selects a project, e.g. How many diabetic patients have had a documented foot exam and lipid profile in the past year? (30 patients sampled)How many diabetic patients have had a documented foot exam and lipid profile in the past year? (30 patients sampled) How frequently are patients in our care management program meeting treatment guidelines for depression? (55 patients)How frequently are patients in our care management program meeting treatment guidelines for depression? (55 patients) DFM support staff assist in patient identification and statistics from EMR DFM support staff assist in patient identification and statistics from EMR

QI Project Presentation Resident presents project, rationale, and results to departmental conference 2-3 months after chronic disease month rotation Resident presents project, rationale, and results to departmental conference 2-3 months after chronic disease month rotation Discussion encouraged Discussion encouraged What can we do differently in our clinic to improve our practice and improve patient outcomes?What can we do differently in our clinic to improve our practice and improve patient outcomes?

Integrating the Chronic Care Model Depression/Panic Disorder Care Management Program Depression/Panic Disorder Care Management Program Systematic case finding with PHQ-9Systematic case finding with PHQ-9 Care managers communicate with patients in between visits, assess severity of depression with PHQ-9Care managers communicate with patients in between visits, assess severity of depression with PHQ-9 Care managers review notes with staff psychiatristCare managers review notes with staff psychiatrist Contact notes entered into EMR for providers to reviewContact notes entered into EMR for providers to review

Other interventions Diabetes initiative Diabetes initiative BC/BS performance feedback BC/BS performance feedback Clinic reorganization into multidisciplinary teams Clinic reorganization into multidisciplinary teams

Group Discussion What are you doing at your program to teach residents about management of chronic disease? What are you doing at your program to teach residents about management of chronic disease? What ideas do you have about how you could enhance your residents’ training to manage chronic diseases? What ideas do you have about how you could enhance your residents’ training to manage chronic diseases?