REALIGNING CHRONIC DISEASE MANAGEMENT for RESIDENCY TRAINING

REALIGNING CHRONIC DISEASE MANAGEMENT for RESIDENCY TRAINING
Michael K. Maharry, MD Anne L. Sullivan, MD University of Iowa Department of Family Medicine

Objectives: We’d like you to:
Understand the process of formulation of a Chronic Disease Management (CDM) curriculum; essential and optional elements Discuss the elements of behavior change instruction as part of a CDM education Realize the relationship with education and quality improvement with a CDM curriculum

Before we begin… 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 is now the principal cause of disability & use of health services Chronic disease consumes 78% of health expenditures Facts about chronic disease in the U.S. 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 Rushed practitioners not following established practice guidelines Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses Result is reduced compliance with treatment, quality of life and health outcomes

Suboptimal Education of Chronic Disease
More Training Needed in Chronic Care: A Survey of U.S. Physicians. Conclusions. Physicians perceived their medical training for chronic illness care was inadequate. Medical schools and residencies may need to modify curricula to better prepare physicians to treat the growing number of people with chronic conditions. Darer, Jonathan D. MD, MPH; Academic Medicine. Special Themes: Educating for Competencies. 79(6): , June 2004.

A Chronic Disease Management Curriculum from thin air…
Step one: Get a team.

Front row: Wendy Shen, George Bergus, Elizabeth Clark, Jo Bowers
Family Medicine Chronic Disease Education Work Group Back row: Jason Wilbur, Lois Albrecht, Alison Abreu, Marcia Gaffney, Anne Sullivan Front row: Wendy Shen, George Bergus, Elizabeth Clark, Jo Bowers

The Chronic Disease TEAM:
Alison Abreu, MD George Bergus, MD, MA Ed Elizabeth Clark, MD MPH Michael Maharry MD Wendy Shen, MD Anne Sullivan MD Jason Wilbur, MD Jo Bowers, MS Marcia Gaffney, RN CDE Lois Albrecht, MS

Step one: Get a team. Share the burden Brainstorm Keep each other on task

Step two: Get a curriculum (Practice what you Teach)

Suggested Goals /Objectives: Competency Style!!
Patient Care: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and promotion of health.

Patient care- residents will: participate in learning motivational interviewing participate in exercises to increase their understanding of the difficulty of behavioral change. learn to integrate new methods of patient education into their continuity clinic patients with chronic disease.

Medical Knowledge: Residents must demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and the application of this knowledge to patient care.

Medical Knowledge- residents will: spend time in the subspecialty clinics of chronic diseases of CHF, CAD/Cardiac rehabilitation, obesity, diabetes, and IMPACT-Chronic Mental Health. Complete ABFM SAM’s on HTN, DM, CAD, Depression learn to work with case managers in applying evidenced-based paradigms of care.

Practice-Based Learning and Improvement: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their patient care practices.

Practice-based Learning and Improvement- residents will: have their clinical skills directly assessed. have their self-management and counseling skills directly assessed. undertake a quality assessment project

Interpersonal and Communication Skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaching with patients, their patients' families and professional associates.

Interpersonal and Communication Skills- residents will: learn the skills of motivational interviewing, learn the skills of self-management patient education gain direct experience by working on their own self-development project

Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse population.

Professionalism- residents will: be mentored in all aspects of professionalism and ethics from interaction with the chronic care team uphold their responsibilities of chronic care as a member of a CDM team

Systems-Based Practice: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Systems-Based Practice-residents will: apply an evidenced-based, multi-faceted system for chronic care realizing the multidimensional aspects of health care. be provided with an opportunity to learn and experience the greater health care system and the extent of its resources through ongoing quality assessment review, along with the interaction with the other professional team members.

Which Chronic Care Model for the Curriculum?
Wagner’s CCM has been shown to improve health outcomes, reduce costs, and/or reduce hospitalizations in a number of chronic diseases, including Hypertension Diabetes Depression Congestive heart failure Chronic obstructive pulmonary disease Bodenheimer, Wagner, Grumbach JAMA 2002

Clinical Information Systems Self- Management Support
Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15): Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78. Improved Outcomes Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice 1998;1:2-4.

Model to Curriculum… Begin to look for ways in your own program (and community) to apply the following 6 major concepts of the Chronic Care Model to the chronic disease curriculum.

Model to Curriculum… 1. Community resources and policies
Home care agencies Senior centers Patient education classes Self help groups

Model to Curriculum… 2. Self management support
Chronic Disease Self-Management Program Residents in attendance and participating Integrate elements of self-management in clinic visits

Model to Curriculum… 3. Decision Support
How do you (or how are you going to provide) evidence-based guidelines for your residents within a new, comprehensive curriculum? What we are doing Self assessment modules from ABFM Guidesheets (clinical/ behavioral) in progress

Model to Curriculum… 4. Clinical information systems Reminder systems
Feedback on performance Disease registries What we are doing Patient panel characteristics

Model to Curriculum… A bit more difficult to tackle (optional)…
5. Delivery system design structure of the practice acute care/chronic care, division of labor what we are doing -care teams

Model to Curriculum… The most difficult of all (optional for you, required for the nation)… 6. Health care organization -have the resident realize the importance of the larger picture, costs, and savings -Starfield articles, advocacy education -Patient-Centered Medical Home

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

To Review Step 1: Get a TEAM Step 2: Get a Curriculum
(Practice what you Teach) Competency Based Wagner Model Based

Goal 2:Discuss the elements of behavior change instruction as part of a CDM education
Personal behavior change Patient self-management

Behavior Change Exercise
Now about your leg crossing….

Behavior Change Instruction
Successful behavior change requires the development of a range of conceptual, assessment and intervention skills. We want residents to: 1. Recognize the elements of physician/patient interaction that have been shown to increase the potential for successful behavior change. And use them in patient encounters to the point that they are “second nature.” 2. Identify essential “constraints” in the life of a patient that may prevent behavior change. And engage patients in conversations intended to “lift” these constraints.

3. Identify a patient’s “personal theory of change”. And use it to initiate and maintain movement through the change process. 4. Identify patient strengths and resources. And “use” them to facilitate changes needed to meet goals. 5. Recognize the value of hope and expectancy in successful Behavioral Change. And be able to design appropriate conversations with patients to facilitate hope and expectancy that change can occur.

6. Recognize that successful Behavioral Change comes not with the application of a particular “technique,” but with learning to incorporate a range of assessment and intervention skills: a. How to Assess Readiness-to-Change (RC) A patient’s position along the Readiness-to-Change continuum (e.g., Precontemplation, Contemplation, Action, Maintenance, Termination). b. How to move patients through the RC continuum. What behavior change strategies should be used when to move patients along the change process?

c. How to set attainable behavior change goals (for nutrition, exercise, smoking cessation, etc.). What are the practical, teachable steps in the goal-setting process? d. How to facilitate a “healing attitude” in patients to guide the behavior change process. Through Motivational Interviewing, facilitating solution-talk, etc.

e. How to “seal” positive changes that occur. Making these behavior changes a more consistent part of the life of the patient. f. How to manage setbacks and relapses.

Last year: 9 weeks of weekly didactic sessions on behavioral change theory and MI……. The Right Clip.wmv

The skills and techniques above will be taught as follows: 1. During intensive behavior change training sessions during resident orientation. 2. During group-focused skill development session sessions scheduled for mid-year (R1). 3. During an R2 rotation focusing on combined behavior change and Behavioral Science topics. 4. Through feedback to residents based on videotaped and/or direct observations of encounters with chronic care patients.

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

Take Charge of Your Health
Chronic Disease Self-Management Workshop Workshop Overview -Working with your doctor -Managing medications -Personalizing a fitness program -Relaxation techniques -Dealing with negative emotions -Managing symptoms -Improving communications -Healthy eating -Setting weekly goals -Effective problem solving -Advanced directives Learn how to take charge of your health and get the most out of life. The Family Care Center offers this workshop for people with chronic health conditions such as diabetes, lung disease, heart disease, high blood pressure, arthritis, depression, multiple sclerosis, and other health problems. People close to someone with a chronic disease can also benefit from the workshop. Meets Wednesdays 3:00 – 5:30 for 6 weeks starting March 26th and going through April 30th. TO SIGN UP FOR THE NEXT SESSION Contact Jo Bowers, Program Coordinator

Self Management Course
chronic_support.wmv

Teaching Chronic Disease Self-Management in Residency Education
Goals of the Self-Management Training Sessions Teach residents to teach patients self-management skills Action planning Problem-solving Methods for interactive education To be used in a clinic session

Structure of Self-Management Training Sessions Two sessions, 2-4 hours long Group participants include CDSM program completers and R1 residents Key Components of each session Feedback/Problem-solving Education session Action planning

Structure of sessions continued: 4. Observe skills modeled by CDSM facilitators 5. Practice skills with supervision Adaptation of Chronic Disease Self-Management Program (CDSMP) in collaboration with UIC Family Medicine (Maureen Gecht)

Goal 3: Realize the relationship with education and quality improvement with a CDM curriculum
QI Project Presentation Resident presents project, rationale, and results to departmental conference later in the year Given protected time Assigned faculty mentor

QI Project 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 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

Goal 3: Realize the relationship with education and quality improvement with a CDM curriculum
Behavioral QI? Evaluation?

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

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

What We did… Changed from 1 month individual rotation to a 2 month focused group curriculum in R1 year Group activities, individual projects Clinical experiences in Family Medicine and specialty clinics managing chronic diseases Residents given panel of patients with diagnoses of DM, HTN, depression etc.

Rotation Sample 3 week Schedule
Monday Tuesday Wednesday Thursday Friday 8-12: Introduction to Chronic Disease Management 8-12: Pulmonary Rehab Clinic 8-12: CHAMPS 8-12: Diabetes Clinic – Internal Medicine 8-12: Family Medicine Center Patient Care 12:15-1: Family Medicine Conference Lunch lunch 1-5: Chronic Disease Didactics 1-5: ABFM Module / QI Project Time 1-5:30: Chronic Disease Didactics & Self-Mgmt Class 1-2: Mentor Meeting 2-5: Home Visit (Sherry McKay) 1-5: Family Medicine Center Patient Care 8-12: Coumadin Clinic 8-12: Rheumatology Clinic 8-12: Geriatrics Clinic 12-1: CHAMPS Multi-Disciplinary Rounds 1-5: UI Spine Center 8-12: CHAMPS – Cardiac Rehab 8-12: IMPACT (Dr. Nancy Williams) 1-5: FCC-Diabetes Clinic 1-5: Nursing Home Rounds

Pros and Cons Pro: focused intensive like a mini-course
all R1 colleagues on same topic early in education to use for remaining time in residency

Pros and Cons Con: Itching to get into clinical medicine
Concept hasn’t sunk in yet “Too long” More theory than practice at this point Difficult changing delivery system

So for The new and improved Chronic Disease Management Curriculum….. Incremental inoculations with hopeful booster effect…

Group Discussion 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?

REALIGNING CHRONIC DISEASE MANAGEMENT for RESIDENCY TRAINING

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