1. Organizing Care for Patients with Chronic Diseases Darren A. DeWalt, MD, MPH Associate Professor University of North Carolina

2. Living with chronic illness is like piloting a small plane icic.org

3. 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 icic.org

4. Usual care works well if your plane is about to crash icic.org

5. Essential Element of Good Chronic Illness Care Informed, Activated Patient Productive Interactions Prepared Practice Team icic.org

6. 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 icic.org

7. 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 icic.org

8. 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? icic.org

9. 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 icic.org

10. Self-management Support Emphasize the patient's central role. Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up. Organize resources to provide support icic.org

11. 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 icic.org

12. Features of case management Regularly assess disease control, adherence, and self-management status Either adjust treatment or communicate need to primary care immediately Provide self-management support Provide more intense follow-up Provide navigation through the health care process icic.org

13. 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. icic.org

14. 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. icic.org

15. 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. icic.org

16. 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. icic.org

17. Let’s Look at Examples Diabetes (Kirkman will discuss) Heart Failure Depression Hypertension Prevention Arthritis (Hawker and Allen will discuss)

18. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes: Reduced Hospitalizations Improved health-related quality of life Delivery System Design: PCP, pharmacist, educator work together to manage patient in office and on phone Decision Support: Guidelines embedded in care system (visit planner) Clinical Information Systems Registry to track patients and ensure receiving core quality Self- Management Support: Literacy appropriate educational materials, reminder calls/education, clearly distilled plans Health System : 4 Academic Health Centers Community Heart Failure Management DeWalt et al. Circulation. 2012 Jun 12;125(23):2854-62. DeWalt et al. BMC Health Serv Res. 2006 13;6:30. McAlister et al. J Am Coll Cardiol. 2004 18;44(4):810-9.

19. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes: Incr. Use of antidepressants Incr. Use of counseling 80% remission in 2 yrs (40% for usual care) Higher role functioning Delivery System Design: PCP, nurse and office staff all involved. Monthly contact with pts by phone via nurse Decision Support: AHCPR guidelines Psychia- trist review and advice on tx adjust Clinical Information Systems Pt roster with tx summaries, feedback to care team Self- Management Support: office nurse provided info on treatment options, readiness intervention, tx effectiveness assessment Health System : 12 PCPs in US metro and non-metro) Community Depression Rost et al BMJ 2002;325:934 icic.org

20. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes: Better Blood Pressure Control Delivery System Design: Pharmacist working together with PCP, Remote visits with home BP. Decision Support: Medication algorithms, refill data, reminders Clinical Information Systems Integrate multiple BP readings, recall if not in control Self- Management Support: Affordable medicine Physical activity Nutrition Goal setting Home BP monitor Health System : Community Hypertension Bosworth et al. Ann Intern Med. 2009 Nov 17;151(10):687-95 Bosworth et al. Am Heart J. 2009 Mar;157(3):450-6.

21. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes: Better functional status, better nutrition, higher screening rates, Delivery System Design: Easy scheduling, pre-visit decision aids, health educator, access to facilities (gym) Decision Support: Reminders to clinical team, information for patients Clinical Information Systems Registry to monitor appropriate screening and counseling Self- Management Support: Physical activity Nutrition Goal setting Navigation for screening Health System : Commitment to prevention Community Access to walking, healthy foods, mindfulness, social capital Prevention

22. Multiple Chronic Illnesses is the Rule, not the Exception

23. Planning Productive Interactions for Chronic Conditions Additional Diagnoses*45% Functional Limits**50% > 2 Symptoms***35% Not Good Health Habits30% *Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung 17%) ** Physical (31%), pain (28%), emotional (16%), daily activities (16%) *** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue(23%), foot (21%), backache (20%) For Example: Diabetic Needs icic.org

24. Number of Chronic Conditions per Medicare Beneficiary Number of Conditions Percent of Beneficiaries Percent of Expenditures 0181 1194 22111 318 41221 5718 6313 7+214 63% 95% icic.org

25. Guidelines are Essential, but not Sufficient

26. Recipe for Improving Outcomes Evidence-based Clinical Change Concepts Learning Model System Change Concepts System change strategy icic.org

27. Drivers for Changing Models of Care Accountable leadership Partnerships that promote quality of care Attractive motivators and incentives Transparent performance measurement Organized quality improvement effort Consumer engagement Plans for sustainability Margolis et al. J Contin Educ Health Prof. 2010;30(3):187-96.

28. How are these levers getting pulled? Motivators and incentives – pay for performance – Payment for Patient Centered Medical Home Transparent performance reporting – NCQA – Public reporting in some markets Organized Quality Improvement – Collaboratives and practice facilitation increasingly available Consumer engagement – Patients like me – Patient associations (Crohn’s and Colitis Foundation)

29. Summary CCM identifies the key aspects of care for the future Successful implementation of CCM improves outcomes across a variety of conditions/prevention Changing the system of care is required to successfully implement the CCM Several levers can influence the pace and success of large-scale system transformation