The Care Model Connie Davis, MN, ARNP Assoc. Director for Clinical Improvement, Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation MacColl Institute Center for Health Studies Group Health Cooperative Seattle, WA

Living with chronic illness is like piloting a small plane

To get safely to their destination pilots need: Self-Management Support Effective Clinical Management Treatment Plan Close Follow-up Flight instruction Preventive Maintenance Safe Flight Plan Air Traffic Control Surveillance

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

Number of Chronic Conditions per Medicare Beneficiary Number of Conditions Percent of Beneficiaries Percent of Expenditures % 95%

Prevalence of chronic conditions 10.3 % have heart disease 23% have high blood pressure 6.2% have diabetes 5% have depression 3% have or had a diagnosis of cancer

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

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 Vitality (not from IOM)

Gaps in Care 25% of patients with diabetes have heart disease risk addressed 27% of patients with hypertension are adequately treated 45% have had colon cancer screening 25% of people with depression are receiving adequate treatment

Why the gap? Irresponsible patients? Uninformed professionals? A broken health care system?

Systems are perfectly designed to get the results they achieve The Watchword

Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation

Evidence-based Clinical Change Concepts A Recipe for Improving Outcomes Learning Model System Change Concepts System change strategy

System Change Concepts Why a Chronic Care Model? In the past, emphasis on physician, not system, behavior Characteristics of successful interventions weren’t being categorized usefully Commonalities across chronic conditions unappreciated.

Model Development 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, prevention and geriatrics Model supported by structured reviews (Renders, 2001; Weingarten, 2002; Bodenheimer, 2002; Norris, 2001) Model now enhanced for all aspects of outpatient care (AHRQ, IHI) and developing nations (WHO)

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? Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patient’s self-management. The provider is viewed as a guide on the side, not the sage on the stage! Informed, Activated Patient

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 Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes

Self-management Support Emphasize the patient's central role. Use effective self-management support strategies (5 A’s). Organize resources to provide support

Delivery System Design Define roles and distribute tasks amongst team members. Use planned interactions to support evidence- based 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 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

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.

Cochrane Review of Interventions to Improve Diabetes Care in Primary Care 41 studies, majority randomized trials Interventions classified as provider-oriented, organizational, information systems, or patient- oriented Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included All 5 studies with interventions in all four domains had positive impacts on patients Renders et al, Diabetes Care, 2001;24:1821

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

Advantages of a General System Change Model Applicable to 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 risks—smoking, 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

"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

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