Thomas bodenheimer


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Thomas bodenheimer

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