The Chronic Care Model

Developed by Ed Wagner, MD, MPH and colleagues MacColl Institute for Healthcare Innovation Group Health Cooperative of Puget Sound home of the Robert Wood Johnson Foundation National Program, Improving Chronic Illness Care Module 3- Intro to ICIC Model

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

The IOM Quality report: A New Health system for the 21st Century “The current care systems cannot do the job.” “Trying harder will not work.” “Changing care systems will.”

Usual Chronic Illness Care 15 minute visit, poorly organized Symptoms and lab results focus of discussion and exam, not preventive assessment Patient’s attempts to discuss difficulties in living with the condition are discouraged Focus is on physician’s treatment, not patient’s role in management. Treatment plan is limited to prescription refill and encouragement to make appointment if not feeling well Visit ends with physician rifling through drawers looking for a pamphlet improving chronic illness care Module 3- Intro to ICIC Model

Functional and Clinical Outcomes Usual Care Model Health System Health Care Organization Leadership concerned about the bottom line Incentives favor more frequent, shorter visits No organized QI Community Resources and Policies No links with community agencies or resources Clinical Information Systems Don’t know pts or what they need Self-Management Support No systematic approach; didactic in orientation Decision Support No agreement on good care; traditional referrals Delivery System Design Reliance on short, unplanned visits Frustrating Problem-Centered Interactions Uninformed, Passive Patient Unprepared Practice Team Sub-optimal Functional and Clinical Outcomes improving chronic illness care Module 3- Intro to ICIC Model

Usual Care Model Frustrating Problem-Centered Interactions Unprepared Practice Team Uninformed, Passive Patient Sub Optimal Functional and Clinical Outcomes improving chronic illness care Module 3- Intro to ICIC Model

Chronic Care Model Productive Interactions Informed, Activated Patient Supportive, Integrated Community Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes Satisfaction  Clinical Measures  Cost  External Review Measures Module 3- Intro to ICIC Model

Chronic Care Model Development 1993 -- Initial experience at GHC Literature review RWJF Chronic Illness Meeting -- Seattle Review and revision by advisory committee (40 members (32 active participants) Interviews and site visits with 72 nominated “best practices” Model applied with diabetes, geriatrics, asthma, CHF, and depression with over 200 health care organizations Module 3- Intro to ICIC Model

Themes in the Chronic Care Model Evidence-based Valuing excellence (and evidence) over autonomy Patient-centered Each patient is the only patient Population-based Module 3- Intro to ICIC Model

The Chronic Care Model Community Health System Resources and Policies Health Care Organization Family Education & Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Supportive, Integrated Community Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes Module 3- Intro to ICIC Model

Chronic Care Model Community Health System Health System Resources and Policies Health System Health Care Organization Health System Clinical Information Systems Family Education & Self-Management Support Delivery System Design Decision Support Specific goals in organizations strategic/business plan Senior leader support Organization adopts performance improvement model Provider incentives support organizational goals I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Module 3- Intro to ICIC Model

Clinical Information Systems Chronic Care Model Community Health System Resources and Policies Health Care Organization Delivery System Design Clinical Information Systems Decision Support Family Education & Self- Management Support Evidence-based guidelines Provider education Referrals and specialist expertise Guidelines for patients I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Module 3- Intro to ICIC Model

Clinical Information Systems Chronic Care Model Community Resources and Policies Health System Health Care Organization Family Education & Self-Management Support Delivery System Design Decision Support Clinical Information Systems Emphasize patient/parent active role Collaborative care planning/problem solving Ongoing educational process Connections between family/patient and social support Standardized assessments of self-management Written management plan with goal setting I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Module 3- Intro to ICIC Model

Chronic Care Model Community Resources and Policies Health System Health Care Organization Family Education & Self-Management Support Delivery System Design Decision Support Clinical Information Systems Team roles and tasks (practice team, school, parents) Care based on accepted guidelines Primary care team assures continuity Regular follow-up care I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Module 3- Intro to ICIC Model

Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Family Education & Self-Management Support Delivery System Design Decision Support Registry to track clinically useful and timely information Registry reports/data for feedback Care reminders Assure timely planned follow-up Identification/proactive care of relevant patient subgroups Individual patient care planning I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Module 3- Intro to ICIC Model

Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Family Education & Self-Management Support Delivery System Design Decision Support Partnerships Key school contact identified Input Educational services available I want to take a few minutes to introduce you to the components of this systems view of the determinants of the health and developmental outcomes of children. The model depicts several key elements of the health care system that influence care. At the center of it all (point to the interaction), is the relationship between the patient and the clinical team that provide care. Thus the focus is on how changes we make result in improvements from the patient’s perspective. As you can see, there are a number of elements: At the top are the health system and the community. The health care organization is inside the health system. Important community resources are outside the health care system. Let me give you some specific examples of each element of the model. Module 3- Intro to ICIC Model

How Would I Recognize Good Care for People with Chronic Illness? Informed, Activated Patient Supportive, Integrated Community Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes Assessment and tailoring Collaborative problem definition Evidence-based clinical management Goal-setting and problem-solving Shared care plan Active, sustained follow-up Community integration and support Module 3- Intro to ICIC Model