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  • 1. La gestión de los cuidados a enfermos crónicos: experiencias en EEUU Caring for people with chronic illness: lessons from the United States Thomas Bodenheimer, MD Professor, Department of Family & Community Medicine University of California, San Francisco, USA
  • 2. % of People in US with a Chronic Illness 45% 57% 1 Chronic Illness 43% 2 or more chronic illnesses Hoffman et al, JAMA 1996;276:1473 56 million people Spain: 47 million
  • 3. Per capita health expenditures, 2008 OECD, 2010 9% of GDP 16% of GDP
  • 4. Average per capita spending by number of chronic conditions (2004) Anderson, “Chronic conditions” Johns Hopkins, 2007
  • 5. If the US is spending so much, we must be doing a great job
      • 27% of discharged CHF patients are readmitted within 30 days [Jencks et al. NEJM 2009;360:1418]
      • 35% of eligible atrial fibrillation patients failed to receive warfarin [Piccini et al. Am J Coll Cardiol 2009;54:1280]
      • Only 15% of smokers are offered assistance to quit [Unrod et al. JGIM 2007;22:478]
  • 6. US: doing a great job??
    • 50% of people with HBP are poorly controlled
    • 62% with elevated LDL-cholesterol have not reached their LDL goal
    • 63% of people with diabetes have HbA1c >7
    • Egan et al. JAMA 2010;303:2043, Afonso et al. Am J Manag Care 2006;12:589, Saydah et al. JAMA 2004;291:335
  • 7. Percent of visits that are primary care 2006 Chronic care is a primary care problem
  • 8. US adult primary care in crisis
    • 9% of medical students choose adult primary care
    • Adult primary care shortage: 40,000 physicians by 2020
    • Average primary care panel: 2300
    • Primary care physician with panel of 2500 average patients would spend 7.4 hours per day doing recommended preventive care [Yarnall,Am J Pub Health 2003;93:635]
    • Primary care physician with panel of 2500 average patients would spend 10.6 hours per day doing recommended chronic care [Ostbye et al. Annals of Fam Med 2005;3:209]
    • Primary care with US panel sizes is an impossible job
    • Yet great energy and dedication to save and improve primary care
  • 9. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model
  • 10. Making the Chronic Care Model work
    • We all know the Chronic Care Model
    • But how do we make it work in the stressed primary care practice?
  • 11. Simplify the Chronic Care Model
      • Decision support
        • Clinical practice guidelines
        • Clinician education
      • Clinical information systems
        • Clinician feedback
        • Reminders
        • Registries
      • Delivery system redesign
        • Planned visits
        • Care management
        • Primary care teams
      • Self-management support
    • Simplify
      • Registries
      • Teams
  • 12. Registries
    • Registries: lists of patients your practice is responsible for
    • Includes clinical information
    • Example: diabetes:
      • Date of last A1c, LDL, blood pressure, eye exam, foot exam, microalbumin,
      • Results of A1c, LDL, blood pressure, etc.
      • What patient education was done?
      • Does patient have a goal and plan to achieve that goal?
    • Cochrane review of 5 trials: registries that identify diabetic patients at risk and bring those patients into care demonstrate reduced HbA1c levels compared with usual care. [Griffin, Kinmouth. Cochrane Library, Issue 3, 2003]
  • 13. Registries and teams
    • A registry is useless unless someone repeatedly and compulsively uses it
      • Searches for care gaps
      • Tries to close the care gaps
    • Care gap = deficiencia en atencion medica
      • Process care gap
        • Patient with diabetes: no HbA1c for 1 year
        • 60 year old woman: no mammogram for 5 years
      • Outcome care gap
        • Patient with diabetes: HbA1c > 9
        • Patient with hypertension: Blood pressure 160/95
    • Requires a team to do this work
  • 14. Registries and teams
    • Implementing Chronic Care Model in primary care must be simple
    • Key components: registry and team
    • For registry to work you need a team
    • Therefore: implementing the Chronic Care Model = team
    • Team is critical because of primary care physician shortage and time it takes to provide good chronic and preventive care
    • If you have a team, you can provide excellent chronic care
    • If you don’t have a team, you can’t
  • 15. It all starts with teams
  • 16. Creating a team culture
    • From I to We :
      • From the lone doctor with “helpers” to the high-functioning team
      • From my patients to our patients
  • 17. Teamwork (trabajo en equipo)
    • Large teams (equipos) are difficult
      • Energy and time spent with many team members having to communicate information and coordinate tasks
      • If one person is not cooperative, the entire team can fail
      • “ The best team size is a team of one.” Dr. Harold Wise, Making Health Teams Work, 1974
    • Smaller teams (teamlets = equipitos) are easier
      • Divide the practice into small 2-person teams (teamlets)
      • Each teamlet responsible for a panel of patients
      • Same 2 people always work together, patients know them and they know the patients
      • Patients learn to trust the teamlet
      • Bodenheimer and Laing, Ann Fam Med 2007;5:457; Bodenheimer T. Building Teams in Primary Care , Parts 1 and 2. California HealthCare Foundation, 2007. www. chcf .org
  • 18. Physician/MA teamlet Patient panel Physician/MA/ teamlet Patient panel Nurse, social worker, pharmacist, health educator, nutritionist, receptionist Patient panel Physician/MA teamlet 1 team, 3 teamlets
  • 19. Two models
    • The I (Yo) Model:
      • Physician orders nurses, medical assistants to do tasks
      • May create resentment in team: not my job, I work for the patients, not for the doctors
    • The We (Nosotros) Model:
      • Entire team is responsible for health of our panel
      • Different people on the team have different responsibilities
      • Re-distributing work is not delegating tasks from physicians to other team members; it is sharing responsibilities
  • 20. Physician, MA, Nurse Patient panel Physician Patient panel MA Tasks Yo model Nosotros model Nurse Tasks
  • 21. Stratify your patients with chronic illness
    • Each teamlet is responsible for a panel of patients. Different patients have different needs
      • Routine chronic and preventive services: medical assistant doing panel management
      • One or two chronic conditions: nurse working with medical assistant doing health coaching
      • Multiple illnesses and complex healthcare needs: doctor with nurse doing complex care management
  • 22. 3 chronic care functions of primary care team
    • Panel management : making sure every patient with a chronic condition has all their evidence-based care done on time
    • Health coaching : making sure every patient with a chronic condition understand their disease, is assisted with healthy behavior change and medication adherence
    • Complex care management : intensive management of high-cost patients with multiple chronic conditions
  • 23. Panel management
    • For patients needing routine preventive and chronic care
    • Cannot work without a registry; the registry identifies care gaps
    • One team member is given protected time to be panel manager -- repeatedly review registry, contact patients needing preventive/chronic care
    • Panel manager works with standing orders/protocols written by physicians
    • Frees up physician for diagnosis, complex patients, care coordination, leading/mentoring the team
  • 24. Individual care to population care
    • Instead of: “what can I do to maximize the care of the 25 patients on my schedule today?”
    • The future: “what can we do today to maximize the care of the 1500 patients in our panel?”
    Monday Patients 8:00AM Mr. Flores 8:15AM Ms. Jones 8:30AM Ms. Rogers 8:45AM Mr. Johnson
  • 25. Panel management: out-reach
    • Calling or writing letters to patients with care gaps (deficiencias de atencion medica)
    • Study
      • Patients with diabetes receiving out-reach letters based on working the diabetes registry
      • Had improved HbA1c and LDL levels
      • Compared to patients whose physicians reviewed the registry and were allowed to decide for themselves how to follow-up
    • KaiserPermanente: “If you really want something done, take it away from the doctors”
      • Stroebel et al. Joint Commission J Qual Improve 2002;28:441
  • 26. Panel management: in-reach
    • In-reach means closing care gaps for patients who come to the primary care practice
    • Requires electronic list of the care gaps
    • Medical assistants or nurses look at the list and close the care gaps. If patient overdue for mammogram, they order the mammogram. Don’t wait for the doctor
    • Research study:
      • Medical assistants reviewed patients’ colorectal cancer screening status from electronic medical record (EMR)
      • For patients without colonoscopy, MAs did patient education, entered referral into EMR
      • Rate of colonoscopy referrals increased by 123% over baseline
      • Educating and reminding physicians did not work
    • Baker et al, Qual & Safety in Heath Care 2009;18:355
  • 27. Panel management: in-reach
    • Kaiser Permanente’s (KP) Southern California region initiated panel management in-reach
    • Every time a KP member comes to a KP facility, the MA reviews the EMR for care gaps and orders whatever is needed to close the care gap
    • Improvements in HbA1c and LDL screening, flu shots, mammograms, Paps, diabetes eye exams, smoking cessation counseling, colorectal cancer screening, control of blood pressure
    • Kanter et al, The Permanente Journal 2010;14:38
  • 28. 3 chronic care functions of primary care team
    • Panel management: making sure every patient with a chronic condition has all their evidence-based care done on time
    • Health coaching : making sure every patient with a chronic condition understand their disease, is assisted with healthy behavior change and medication adherence
    • Complex care management: intensive management of high-cost patients with multiple chronic conditions
  • 29. Health coaching
    • Nurses, medical assistants, community health workers, health educators, and patients can be trained as health coaches (promotoras)
    • Main tasks:
      • Make sure patient understands what happened in the visit (50% of patients do not understand)
      • Make sure patient agrees with the physician’s care plan (90% are never asked if they agree)
      • Assist patients with setting goals for lifestyle changes
      • Make sure patients understand their medications and take their medications
  • 30. Physician and health coach (promotora) meet with patient
  • 31. Health coaching
    • Teamlets with trained medical assistant health coaches paired with family physicians significantly improved smoking and BMI (body mass index) documentation, more behavior-change action plans done, and more LDL testing compared with comparison group
    • Teamlet patients had better A1c, LDL, blood pressure vs. comparison group but not quite statistically significant
    • Chen et al. J Gen Intern Med 2010;25(suppl 4):610
  • 32. Goal-setting and action plans
    • Patient with diabetes chooses goal: to eat more healthy
    • Unrealistic action plan:
    • “ I will never eat ice cream”
    • Realistic action plan: “Instead of eating a bowl of ice cream every night, I will eat half a bowl twice a week. I am 80% sure I can do it.”
    • Follow-up crucial for action plans
  • 33. Action plans
    • A major responsibility of health coaches is to engage patients in behavior-change action plans
    • Study:
      • Patients with diabetes who made action plans had a reduction in HbA1c (8.9 to 8.0) compared with patients receiving education without action plans (HbA1c 8.7 to 8.7)
      • The improvement was maintained 1 year after the action plans were done
      • Naik et al. Arch Intern Med 2011;171:453
  • 34. Medical assistants as health coaches
    • Patients with depression cared for by a medical assistant/physician teamlet had significantly better outcomes (lower PHQ-9 scores) than patients cared for by physicians alone
    • The medical assistants felt
      • More professional enrichment from the new role
      • Comfortable with the new role
    • Gensichen et al. Ann Intern Med 2009;151:369, Gensichen et al, Ann Fam Med 2009;7:513
  • 35. Health coach doing medication education
  • 36. 3 chronic care functions of primary care team
    • Panel management: making sure every patient with a chronic condition has all their evidence-based care done on time
    • Health coaching: making sure every patient with a chronic condition understand their disease, is assisted with healthy behavior change and medication adherence
    • Complex care management : intensive management of high-cost patients with multiple chronic conditions
  • 37. Average per capita spending by number of chronic conditions (2004) Anderson, “Chronic conditions” Johns Hopkins, 2007
  • 38. Complex care management
    • Panel management, health coaching: not for patients with complex healthcare needs/high costs
    • Nurse care management is needed, with intensive nursing individualized to each patient
    • Nurse complex care managers work with physicians, pharmacists, social workers
    • Studies: complex care management improves care and may reduce costs for patients with complex healthcare needs
    • Reduces physician time with complex patients
      • Bodenheimer and Berry-Millett, Care Management of Patients with Complex Healthcare Needs, Robert Wood Johnson Foundation, 2009 (www.rwjf.org/pr/synthesis.jsp)
  • 39. Complex care management
    • Geriatric Resources for Assessment and Care of Elders (GRACE) ( Indiana University Medical School)
      • Nurse practitioner/social worker care manager team working with primary care physician and geriatrician
      • In-clinic, home and phone contacts
      • Extensive training of care manager team
      • Small case load (100-120) for care manager team
      • Higher-risk subgroup had significantly lower hospitalization rate than higher-risk usual care patients
    • Counsell et al, JAMA 2007;298:2623
  • 40. Complex care management
    • Care Management Plus (Intermountain Health Care in Utah)
      • Extensive training of care manager nurses
      • Care managers work with primary care team
      • Clinic visits, home visits, phone calls
      • In the higher-risk subgroup, hospital admissions significantly lower in care managed group
    • Dorr et al, JAGS 2008;56:2195
  • 41. Complex care management
    • Guided Care (Johns Hopkins)
      • Extensively trained RN care managers work with primary care team, case loads about 50
      • Clinic visits, home visits, phone calls
      • RNs teach patients/families self-management skills including early identification of symptom worsening
      • Improved several quality measures
      • No reduction in ED visit or hospital days
    • Boult et al, Arch Intern Med 2011;171:460
    • Boult et al. Guided Care (Springer Publishing Co, 2009)
  • 42. Hospital to home care management
      • Mary Naylor’s model (Univ of Pennsylvania)
      • Nurse practitioners work with patients during hospitalization and post-hospital at home with at least 8 home visits and phone contact
      • Extensive care manager training
      • Reduced hospital and emergency department utilization compared to controls, with 38% total cost reduction
    • Naylor et al. JAGS 2004;52:675
  • 43. Hospital to home care management
    • Care Transitions Intervention: Eric Coleman’s model (University of Colorado)
    • Nurses trained as “transition coaches” to teach patients/families skills to care for themselves
    • 1 hospital visit, 1 home visit post-discharge, 3 post-discharge phone calls
    • Significantly lower readmission rates and lower hospital costs compared with controls
    • Less intensive intervention than Mary Naylor’s model
    • Coleman et al, Arch Intern Med 2006;166:1822
  • 44. Complex care management
    • Initial long meeting of patient/family with care team (physician, nurse, social worker, pharmacist)
    • Care plan made with team and patient/family
    • Nurse care manager responsible for implementing and assessing care plan, teaching about meds, red flags
    • Nurse does phone, home-visit f/u, consults with physician/team
    • Regular team meetings
    • Case load 50-70 patients
    • Will not work unless panel management and health coaching are implemented to give physician time for complex patients
  • 45. Clinica Family Health Services -- Colorado (Clinica Campesina)
    • Most patients poor, speak only Spanish
    • Patients almost always see same teamlet (clinician and medical assistant)
    • 3 teamlets within larger team including nurse, health coach (promotora), behavioral health professional. All team members in same room
    • Medical assistants do panel management
    • Health coach: patient education, goal-setting/ action plans for patients with chronic illness
    • Clinica is starting complex care management
  • 46. Co-location of team
    • Picture of the co location
  • 47. Patients get “tarjeta de visita” with names of their teamlet
  • 48. Teamlet discussing a patient
  • 49. Primary care revolution in the US
    • Many primary care practices are initiating team care for patients with chronic illness
      • Large systems (Kaiser Permanente)
      • Community health centers
    • Small private practices are slowly joining
    • This revolution is called Patient-Centered Medical Home
    • We have many challenges but are determined to succeed