1. Understanding & Improving the Quality of Chronic Care: Moving Beyond the Vanguard Practices Brian Austin Deputy Director Improving Chronic Illness Care AcademyHealth Annual Research Meeting June 7, 2004

2. ICIC Mission and Initial Strategy Mission –To assist health systems, especially those serving low income populations, improve their care of the chronically ill through quality improvement, research, and dissemination Strategy –QI - use Breakthrough Series to promote CCM-guided system change, and externally evaluate –Research - promote innovation in care delivery through research grants and our own research –Dissemination - spread advances and tools in chronic care (and help build field) through direct communication with potential users, and through partnerships Funded through a grant from The Robert Wood Johnson Foundation

3. Evidence-based Clinical Change Concepts Evidence-based System Change Concepts A Recipe for Improving Outcomes System Change Strategy Learning Model

4. Evidence-based Clinical Change Concepts System Change Concepts System Change Strategy Learning Model A Recipe for Improving Outcomes

5. Variations on the Chronic Care Model

7. WHO’s Care for Chronic Conditions Framework

9. Evolution of Regional Collaborative Strategy WA experience demonstrated advantages of regional approach –Builds capacity for broader, sustained activity –Opportunity to engage plans, payors, and government –Social relationships add power ICIC funded collaborative sponsors like QIOs or State health departments (seven grantees) Several have conducted multiple collaboratives Collaboratives Plus—adding system change capacity to regional QI

10. Regional Collaboratives Washington State: Diabetes I,II, III Alaska Oregon: Diabetes, CHF Chicago Vermont New Mexico Wisconsin North Carolina Rhode Island Maine Arizona Nevada Colorado

11. A Steady Rise in Participants Note: Represents approx. 150,000 pts in pilot populations

12. ICIC Involvement in Chronic Care Improvement

13. Types of Systems Participating in Regional Collaboratives Note: This does not include BPHC collaboratives.

14. Indiana: An Example of “Collaboratives Plus”

15. Indiana: Program Objectives –Provide consistently high quality care to Medicaid recipients that improves health status, enhances quality of life and teaches self management skills. –Reduce the overall cost of providing health care to Medicaid patients suffering from chronic diseases. –Provide support to primary care providers and integrate primary care with case management. –Utilize and strengthen the public health infrastructure. –Achieve long term results by changing the way primary care is delivered across the state, not just for Medicaid.

16. Assembling the Infrastructure Assemble “best pieces” to build and strengthen the existing public that will facilitate the interaction health infrastructure between primary care and chronic disease case management statewide –State Health Department – clinical expertise, physician committees, medical community ties –Existing Vendors – member enrollment, reminder calls to patients, inbound and outbound call center, data integration –Community Partners –community health centers, FQHCs, public health associations, minority health coalitions and other community entities to offer face to face case management –Technology - data registry that facilitates efficient communication between call center, case managers and physicians and also provides adequate reporting functionality

17. –Program Management: Medicaid and Health are jointly responsible for the program including policy development, contracting and monitoring performance. –Primary Care: The focal point of patient care is the primary care physician. Key elements of the Indiana CDM program are designed to provide information & resources to support the physician. –Care Management. Care management is comprised of: A Call Center that monitors patient status and follow-up based on the established protocols. A Nurse Care Manager network whose nurses provide more intense follow up and support to high risk patients. –Patient Data Registry. An electronic data registry is available to physicians and can be used for all patients. For Medicaid patients, it will be populated with claims data and case management data. –Measurement & Evaluation. Measures of program performance are being established using both claims history data and individual health outcomes indicators for both an intervention & control group. Main Program Components

18. Case Management Client Flow Community Resources Self Management Training Nurse Case Management 15 - 20% of Patients Patient Registry CDMS Web-Based Chronic Care Model Collaborative Training Decision Support Call Center 80 - 85% of Patients Patient Provider

19. Indiana Program Implementation Schedule PeriodRegionCondition State July – December 2003 CentralCHF, Diabetes January – March 2004 NorthernCHF, Diabetes, Asthma (also add asthma for Central) April – June 2004SouthernCHF, Diabetes, Asthma July – September 2004 StatewideHigh risk patients

20. Bringing System Change to Small Practices Practice redesign is very difficult in the absence of a larger, supportive “system” “Systemness” (and measurable improvement) in the US generally comes from a larger organization (e.g., BPHC, Kaiser, VA) In addition to limited staff and IT, smaller practices need additional help because of multiple health plans, reduced reimbursement and productivity pressures Is it possible to develop a regional strategy that can bring support and “systemness” to large numbers of practices?

21. Community entity provides: Leadership and integration via coalition Performance measurement Financial incentives Models of change Programs for learning and dissemination Shared infrastructure 1.Guidelines 2.IT software and support 3.Care management 4.Consumer education “Systemness” as a Community Property Improved Community Outcomes Widespread Practice Change Health Systems in a Community

22. www.improvingchroniccare.org Contact us: Thanks

23. Advantages of a General System Change Model Commonalities across chronic conditions easier to see and apply. Characteristics of successful interventions could be categorized usefully Once system changes in place, accommodating new guideline or innovation much easier Emphasis on system, not physician behavior Applicable to most preventive and chronic care issues

24. 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

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

26. 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

27. 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

28. 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?

29. 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

30. 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

31. 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.

32. 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.

33. 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.

34. 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.

35. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo

36. Chronic Conditions Breakthrough Series Select Topic Planning Group Identify Change Concepts Participants Prework LS 1 P S AD P S AD LS 3 LS 2 Supports E-mailVisits Web-site PhoneAssessments Senior Leader Reports Nat’l.C. AD P S (13 months time frame)