Planned Chronic Care Visits Tom Bodenheimer UCSF Department of Family and Community Medicine

Tyranny of the urgent

Primary care clinicians have too many issues to deal with in the average 18 minute visitPrimary care clinicians have too many issues to deal with in the average 18 minute visit Acute problems crowd out time for routine management of chronic illnessAcute problems crowd out time for routine management of chronic illness

Chronic Care Model components Decision support Decision support –Clinical practice guidelines –Clinician education Delivery system redesignDelivery system redesign Planned visits Planned visits –Case management –Primary care teams Clinical information systemsClinical information systems –Clinician feedback –Reminders –Registries Self-management supportSelf-management support

What is a Planned Visit? A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit.A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit. The provider’s objective is to deliver evidence- based clinical management and patient self- management support at regularly scheduled intervals without the “noise” inherent in the acute care visit.The provider’s objective is to deliver evidence- based clinical management and patient self- management support at regularly scheduled intervals without the “noise” inherent in the acute care visit.

Delivery system redesign: Planned visits Planned visits can combat the “tyranny of the urgent” by separating chronic care and acute visitsPlanned visits can combat the “tyranny of the urgent” by separating chronic care and acute visits Planned visits for people with relatively stable chronic illness -- or chronic illness that requires a lot of patient education, collaborative decision making, and goal setting -- could be performed by nurses, pharmacists, or other caregivers using physician-created protocolsPlanned visits for people with relatively stable chronic illness -- or chronic illness that requires a lot of patient education, collaborative decision making, and goal setting -- could be performed by nurses, pharmacists, or other caregivers using physician-created protocols

Delivery system redesign: Planned visits Planned group visits for diabetics significantly reduced HbA1c levels and hospital use for diabetics in Kaiser system (RCT) [Sadur et al. Diabetes Care 1999;22:2011]Planned group visits for diabetics significantly reduced HbA1c levels and hospital use for diabetics in Kaiser system (RCT) [Sadur et al. Diabetes Care 1999;22:2011] Individual planned diabetes mini-clinic visits can improve outcomes if the patients actually come to the visits [Wagner EH et al. Diabetes Care 2001;25:695.]Individual planned diabetes mini-clinic visits can improve outcomes if the patients actually come to the visits [Wagner EH et al. Diabetes Care 2001;25:695.].

Delivery system redesign and clinical information systems: planned visits + reminders A Cochrane Review looked at trials comparing a control group with patients who had planned follow-up visits and whose physicians had reminder prompts. 5 trials were found: the intervention group had significantly lower HbA1c in all 5 trials. [Griffin, Kinmouth. Cochrane Review, 2001] A Cochrane Review looked at trials comparing a control group with patients who had planned follow-up visits and whose physicians had reminder prompts. 5 trials were found: the intervention group had significantly lower HbA1c in all 5 trials. [Griffin, Kinmouth. Cochrane Review, 2001]

Delivery system redesign: Planned visits A Danish study of 970 patients with diabetes cared for by 474 physicians, comparing usual care with planned visits and other improvements, found that HbA1c, blood pressure, and lipids were significantly lower in the intervention group.A Danish study of 970 patients with diabetes cared for by 474 physicians, comparing usual care with planned visits and other improvements, found that HbA1c, blood pressure, and lipids were significantly lower in the intervention group. Olivarius et al. BMJ 2001;323:970.

Delivery system redesign: Planned visits Peters and Davidson demonstrated that patients attending a nurse-led diabetes planned visit clinic had improved HbA1c levels that were also lower than usual care patients. Aubert came to similar conclusions.Peters and Davidson demonstrated that patients attending a nurse-led diabetes planned visit clinic had improved HbA1c levels that were also lower than usual care patients. Aubert came to similar conclusions. Peters and Davidson, Diabetes Care 1998;21:1037 Aubert et al. Annals Intern Med 1998;129:605.

Delivery system redesign: Planned visits According to a Cochrane review, seven studies in which nurses conducted planned diabetes care visits all demonstrated a positive impact on glycemic control. The review concluded that nurses “can even replace physicians in delivering many aspects of diabetes care, if detailed management protocols are available, or if they receive training.”According to a Cochrane review, seven studies in which nurses conducted planned diabetes care visits all demonstrated a positive impact on glycemic control. The review concluded that nurses “can even replace physicians in delivering many aspects of diabetes care, if detailed management protocols are available, or if they receive training.” Renders et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Review. In Cochrane Library Issue 3, 2001.

Self-management support Educating patients about their specific chronic disease and teaching them technical skillsEducating patients about their specific chronic disease and teaching them technical skills Training patients in problem-solving and goal-setting skills to assist in healthy behavior changeTraining patients in problem-solving and goal-setting skills to assist in healthy behavior change

Self-management support Both aspects of self-management support are needed. Example: diabetes Comprehensive review of traditional patient education: 33/46 studies showed improved patient knowledge/ skills, but only 18/54 demonstrated improved glycemic control [Norris et al. Diabetes Care 2001;24:561]Comprehensive review of traditional patient education: 33/46 studies showed improved patient knowledge/ skills, but only 18/54 demonstrated improved glycemic control [Norris et al. Diabetes Care 2001;24:561] Adding problem-solving/goal setting skills training reduces HbA1c compared with controls [Anderson et al. Diabetes Care 1995;18:943]Adding problem-solving/goal setting skills training reduces HbA1c compared with controls [Anderson et al. Diabetes Care 1995;18:943]

Delivery system redesign: Planned visits Planned visits can do both aspects of self-management support -- patient education and collaborative goal- settingPlanned visits can do both aspects of self-management support -- patient education and collaborative goal- setting The best planned visits also do medication managementThe best planned visits also do medication management

Delivery system redesign: Planned visits Can be individual visits or group visitsCan be individual visits or group visits

What does a Planned Visit look like? The provider team proactively calls in patients for a longer visit (20-40 minutes) to systematically review care priorities.The provider team proactively calls in patients for a longer visit (20-40 minutes) to systematically review care priorities. Visits occur at regular intervals as determined by provider and patient.Visits occur at regular intervals as determined by provider and patient. Team members have clear roles and tasks.Team members have clear roles and tasks. Delivery of clinical management and patient self- management support are the key aspects of care.Delivery of clinical management and patient self- management support are the key aspects of care. Protocols need to be prepared before initiating planned visits that include medication managementProtocols need to be prepared before initiating planned visits that include medication management

Example: Patients with type 2 diabetes. Step One Choose a patient sub-population, e.g., all patients A1c >9.5 from registryChoose a patient sub-population, e.g., all patients A1c >9.5 from registry Identify patients who have not been seen recently as prioritiesIdentify patients who have not been seen recently as priorities Review chart for needed medical managementReview chart for needed medical management

Step Two: Patient Outreach Have front office call patient and explain the need for planned visitHave front office call patient and explain the need for planned visit Allow patient to choose day and time for visitAllow patient to choose day and time for visit Ask patient to come to lab for A1c one week prior to visitAsk patient to come to lab for A1c one week prior to visit Ask patient to bring in all medications and any blood sugar dataAsk patient to bring in all medications and any blood sugar data

MA prints patient summary from registries and attaches to front of chartMA prints patient summary from registries and attaches to front of chart Care manager (usually nurse or pharmacist) who runs the planned visit reviews medications and labs prior to visit, and consults with physician as neededCare manager (usually nurse or pharmacist) who runs the planned visit reviews medications and labs prior to visit, and consults with physician as needed Step Three: Preparing for the Visit

Review and tweak patient’s medication regimenReview and tweak patient’s medication regimen Examine feetExamine feet Referrals for eye care/other specialties as neededReferrals for eye care/other specialties as needed Self-management educationSelf-management education Self-management goal setting with an patient action planSelf-management goal setting with an patient action plan Schedule follow-upSchedule follow-up Different team members can do different portions of these tasksDifferent team members can do different portions of these tasks Step Four: The Visit

Does not need to be in-person visit (use phone, )Does not need to be in-person visit (use phone, ) Check success in achieving action planCheck success in achieving action plan Problem solve as neededProblem solve as needed Schedule additional follow-up as neededSchedule additional follow-up as needed Step Five: Follow-up

My personal view To initiate chronic care improvement in public hospital systems, changing primary care is the hardest, because the daily stresses are so greatTo initiate chronic care improvement in public hospital systems, changing primary care is the hardest, because the daily stresses are so great A good way to start is the Lyn Berry/ Phyllis Preciado strategy at Alameda County Medical Center: start with a planned care clinicA good way to start is the Lyn Berry/ Phyllis Preciado strategy at Alameda County Medical Center: start with a planned care clinic

My personal view A planned care clinic can often be established with no budget or a very small budget. It requires senior leader support to arrange space and assign the necessary personnel to the planned care clinic 1 day or 1/2 day per week.A planned care clinic can often be established with no budget or a very small budget. It requires senior leader support to arrange space and assign the necessary personnel to the planned care clinic 1 day or 1/2 day per week. Appointment clerk, medical assistant, health educator, pharmacist, nurse, physician. Also, use studentsAppointment clerk, medical assistant, health educator, pharmacist, nurse, physician. Also, use students

My personal view In a planned care clinic one can start to initiate chronic care model components on a small scale, later to be spread to primary care sitesIn a planned care clinic one can start to initiate chronic care model components on a small scale, later to be spread to primary care sites –Registry with reminder system –Self management education including collaborative goal setting –Team development with clear division of labor –Creating simple practice guidelines embedded in a diabetes/CV risk reduction progress note –The clinic is training nurses and pharmacists to do case management for diabetes/CV risk reduction

Five basic types of group visits Three Clinical: Cooperative Care ClinicCooperative Care Clinic Continuing Care ClinicsContinuing Care Clinics Nurse-led group visitsNurse-led group visits Two Social Support : Chronic Disease Self-management ProgramChronic Disease Self-management Program Support GroupsSupport Groups

DIGMAs: Drop In Group Medical Appointments? Anecdotal data onlyAnecdotal data only Undergoing trial at presentUndergoing trial at present Provider satisfaction is highProvider satisfaction is high Increased productivity Increased productivity Described extensively by Noffsinger

Some things to know about Group Visits Can be logistically tough to organizeCan be logistically tough to organize Once established, excellent economies of scaleOnce established, excellent economies of scale High patient satisfactionHigh patient satisfaction 30-40% of patients will enroll30-40% of patients will enroll Excellent way to utilize other clinical/non- clinical staffExcellent way to utilize other clinical/non- clinical staff HIPPA concerns easily addressedHIPPA concerns easily addressed

Bottom line: Planned visits, whether group or individual, are key to improved chronic care