The Chronic Care Model Overview National Consultation, Central American Diabetes Initiative (CAMDI) (Managua, Nicaragua, 2–3 July 2007)

Chronic Diseases Background Globally, 60% of all deaths are due to chronic diseases Majority of chronic disease deaths occur in low and middle income countries Threat is growing – the number of people, families and communities afflicted is increasing Globally, 60% of all deaths are due to chronic diseases Majority of chronic disease deaths occur in low and middle income countries and these deaths occur in equal numbers among men and women The threat is growing – the number of people, families and communities afflicted is increasing

Chronic Diseases Background (cont) Chronic disease has major adverse effects on quality of life In low-income countries, middle-aged adults are especially vulnerable to chronic disease Chronic disease hinders the economic development of many countries Chronic disease has major adverse effects on the quality of life of affected individuals. In low-income countries, middle-aged adults are especially vulnerable to chronic disease. Chronic disease results in millions of premature deaths thereby hindering the economic development of many countries

Background The chronic disease threat can be overcome: Common, modifiable risk factors underlie the major chronic diseases The science exists for optimal disease management The solutions are effective – and highly cost-effective

What must be done? To evolve from acute focused ‘find it and fix it’ health care systems towards ones that are proactive, provides comprehensive and coordinated care and are designed to meet the long term needs of patients. ‘ Trying harder will not work. Current health systems cannot do the job. Changing care systems will ’. US Institute of Medicine, 2001

Chronic Care Model The Chronic Care Model developed by the MacColl Institute for Healthcare Innovation (USA) provides a road map for redesigning the system to better manage chronic conditions This model can be applied to a variety of chronic illnesses, health care settings and target populations www.improvingchroniccare.org

Chronic Care Model The model has been adopted by the WHO as the basis for its framework for managing chronic conditions Is used in many countries and health care organizations around the world Has been shown to improve patient outcomes and reduce costs for many chronic conditions www.who.int/chp

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive COMMUNITY Health Care Organizations Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive Health Care Organizations COMMUNITY Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Health Care Organizations Visibly support improvement in chronic illness care at all levels of the organization Provide incentives to encourage better chronic illness care Facilitate care coordination throughout the organization

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive COMMUNITY Health Care Organizations Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Community Resources & Policies Form partnerships with community organizations to support and develop interventions that fill gaps in needed services Encourage patients to participate in effective community programs Advocate for policies to promote health, prevent disease and improve patient care

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive COMMUNITY Health Care Organizations Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Self-Management Support Emphasize the patient’s central role in managing his/her health Use effective self-management support strategies that include goal setting, action planning and problem-solving Organize internal and community resources to provide ongoing self-management support to patients

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive COMMUNITY Health Care Organizations Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Decision Support Embed evidence-based guidelines into daily clinical practice Share evidence-based guidelines and information with patients to encourage their participation Integrate specialist expertise and primary care

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive COMMUNITY Health Care Organizations Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Delivery System Design Define roles and distribute tasks among team members Use planned interactions to support evidence-based care Ensure regular follow-up by the care team Give care that patients understand and that fits with their cultural background

Chronic Care Model Improved Outcomes HEALTH SYSTEM Productive COMMUNITY Health Care Organizations Self- Management Support Clinical Information System Resources & Policies Delivery System Design Decision Support Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

Six Focal Areas Clinical Information Systems Provide timely reminders for providers and patients Identify subpopulations for proactive care Facilitate individual care planning Share information with patients and providers to coordinate care Monitor performance of practice team and care system

Assessment of Chronic Illness Survey Tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness Evaluates the organization of care rather than outcome, process or productivity measures Provides baseline information and guidance as to the system changes needed to improve care Survey questions focus on the six areas of system change identified by the Chronic Care Model as influencing quality of care

Assessment of Chronic Care 1 2 3 4 5 6 7 8 9 10 11 N=90 Mean Rating (0-11) Organization Self-Management Decision Support Community Linkages Information Systems Delivery System Redesign

Questions