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Chronic illness

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Chronic illness

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Chronic illness

  1. 1. Redesigning Chronic Illness Care: The Chronic Care Model Ed Wagner, MD, MPH MacColl Institute for Healthcare Innovation Center for Health Studies Group Health Cooperative Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation IHI National Forum December 10, 2007
  2. 2. Chronic Illness in America • More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them. • Despite annual spending of well over $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care. • Gaps in quality care lead to thousands of avoidable deaths each year.. • Patients and families increasingly recognize the defects in their care.
  3. 3. Chronic Illness and Medical Care • Primary care dominated by chronic illness care • Clinical and behavioral management increasingly effective BUT increasingly complex • Inadequate reimbursement and greater demand forcing primary care to increase throughput—the hamster wheel • Unhappy primary care clinicians leaving practice; trainees choosing other specialties • Loss of confidence in primary care by policy-makers and funders • But, there are new models of primary care and growing interest in changing physician payment to encourage and reward quality
  4. 4. What Patients with Chronic Illnesses Need • A “continuous healing relationship” with a care team and practice system organized to meet their needs for: Effective Treatment (clinical, behavioral, supportive), Information and support for their self-management, Systematic follow-up and assessment tailored to clinical severity, More intensive management for those not meeting targets, and Coordination of care across settings and professionals
  5. 5. Why are we doing so poorly? The IOM Quality Chasm report says: • “The current care systems cannot do the job.” • “Trying harder will not work.” • “Changing care systems will.”
  6. 6. What’s Responsible for the Quality Chasm? • A system oriented to acute disease that isn’t working for patients or professionals
  7. 7. What kind of changes to practice systems improve care?
  8. 8. Randomized trials of system change interventions: Diabetes Cochrane Collaborative Review • 41 studies, majority randomized trials • Interventions classified as provider-oriented, organizational, information systems, or patient-oriented • Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included • All 5 studies with interventions in all four domains had positive impacts on patients Renders et al, Diabetes Care, 2001;24:1821
  9. 9. Shojania, K. G. et al. JAMA 2006;296:427-440. The Effectiveness of QI Strategies: Findings from a Recent Review of Diabetes Care
  10. 10. Toward a chronic care oriented system Reviews of interventions in other conditions show that practice changes are similar across conditions Integrated changes with components directed at:  use of non-physician team members,  planned encounters,  modern self-management support,  Intensification of treatment  care management for high risk patients  electronic registries
  11. 11. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model
  12. 12. What distinguishes good chronic illness care from usual care? Informed, Activated Patient Productive Interactions Prepared Practice Team
  13. 13. • Assessment of self-management goal attainment and confidence as well as clinical status • Adherence to guidelines • Tailoring of clinical management by stepped protocol (Treat to target) • Collaborative goal-setting and problem-solving resulting in a shared care plan • Planning for active, sustained follow-up Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?
  14. 14. What characterizes an “informed, activated patient”? Informed, Activated Patient They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.
  15. 15. Self-Management Support Goal To help patients take a more active role and be more competent managers of their health and healthcare.
  16. 16. Community Resources and Policies Goal To help patients access effective and useful services and resources in the surrounding community.
  17. 17. What characterizes a “prepared” practice team? Prepared Practice Team Practice team and interactions with patients organized to help patients reach clinical targets and self-management goals. .
  18. 18. Delivery System Design Goal To organize practice staff, schedules and other systems to assure that all patients receive planned, evidence-based care.
  19. 19. Decision Support Goal To assure that clinicians and other staff have the training, scientific information and system support to routinely provide evidence-based (adhere to guidelines) and patient-centered care.
  20. 20. Clinical Information System Goal To assure that clinicians and other staff have ready access to patient information on individuals and populations to help plan, deliver and monitor care.
  21. 21. Health Care Organization Goal To assure that practices within the organization have the motivation, support and resources needed to redesign their care systems.
  22. 22. The Evidence Base Does the CCM Work?
  23. 23. Organizing the Evidence 1. Randomized controlled trials (RCTs) of individual interventions to improve chronic care 2. Studies of the relationship between organizational characteristics and quality improvement 3. Evaluations of the use of the CCM in Quality Improvement 4. RCTs of CCM-based interventions 5. Cost-effectiveness studies
  24. 24. Studies in other conditions confirm that the elements found effective in diabetes care apply to other chronic conditions as well. 1: RCTs of interventions to improve chronic care results
  25. 25. 2: Studies of the Relationship between Organizational Characteristics and Quality • Studies measure adherence to the CCM via self- assessment or external observer • Analyses either compare high and low performers or correlate degree of CCM implementation with performance • Studies show that quality improves with fuller implementation of the CCM • Most studies cross-sectional; don’t answer the question whether going to trouble of redesigning practice improves performance.
  26. 26. Study of in 20 Texas Primary Care Practices • Practices evaluated themselves using the ACIC • Researchers reviewed diabetic charts • Analysis looked at relationship between ACIC scores and 10 yr. risk of CHD (HbA1c, BP, LDL, smoking) • Higher ACIC associated with reduction in modifiable CHD risk (full implementation of CCM reduced average risk over 50%). Parchman et al. Medical Care, Dec. 2007 Several studies have demonstrated a relationship between practice characteristics consistent with the CCM and performance
  27. 27. 3: Evaluations of the Use of CCM in Quality Improvement • 3 major evaluations - RAND Evaluation of ICIC collaboratives - Landon evaluation of the Health Disparities collaboratives - Chin evaluation of HDC in the midwest • All studies focus on diabetes • Methods differed - RAND compared collab. participants with other practices in the org. - Landon compared entire CHCs that were and were not involved in the HDC with 1 yr. follow-up - Chin looked at entire CHCs involved in the HDC over 4 year period
  28. 28. 3: RAND Evaluation of Chronic Care Collaboratives • Two major evaluation questions: 1. Can busy practices implement the CCM? 2. If so, would their patients benefit? • Studied 51 organizations in four different collaboratives, 2132 BTS patients, 1837 controls with asthma , CHF, diabetes • Controls generally from other practices in organization • Data included patient and staff surveys, medical record reviews
  29. 29. 3: RAND Findings Implementation of the CCM • Organizations made average of 48 changes in 5.8/6 CCM areas • IT received most attention, community linkages the least • One year later, over 75% of sites had sustained changes, and a similar number had spread to new sites or new conditions.
  30. 30. 3: RAND Findings: Patient Impacts • Diabetes pilot patients had significantly reduced CVD risk (pilot > control), resulting in a reduced risk of one cardiovascular disease event for every 48 patients exposed. • CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days and fewer ER visits • Asthma and diabetes pilot patients more likely to receive appropriate therapy • Asthma pilot patients had better QOL
  31. 31. 3: Evaluations of the Health Disparities Collaboratives • Landon evaluation showed process but not outcome improvements in the year following the end of participation • Chin showed process improvements in the following year followed two years later by significant reductions in HbA1c and LDL. • My hunch: Participating practices saw short-term improvements in both process and outcomes (RAND), and the spread of process changes to other practices in the system began shortly thereafter, but was slow and didn’t impact clinic-wide outcomes for another year or two.
  32. 32. 4: Randomized Controlled Trials (RCT) of CCM-based Interventions • 6 RCTs covering asthma, diabetes, bipolar disorder, comorbid depression and oncology, and multiple conditions • 5 in the US – disease specific, 1 in Australia – multiple diseases • Practice-level randomization • 5 of 6 showed significant improvements in patient health
  33. 33. 5: Cost Study Results • Some evidence that improved disease control can reduce healthcare costs, especially for congestive heart failure, asthma (among populations with high ER and hospital use) and uncontrolled diabetes • Better depression control does not appear to reduce healthcare costs, but increases work productivity • Huang et al. showed that HDC participation had a favorable CE ratio
  34. 34. Challenges in Implementing the CCM • Practices spent considerable time searching for/developing tools • Some practices felt intimidated by taking on the whole model – asked for a sequence • Many changes were made in ways that were not sustainable logistically or financially (e.g., double data entry) • CCM elements implemented as “special events” rather than part of routine care • Many achieve process improvements but outcomes don’t change
  35. 35. Why do practices who have changed their system not see improvements in key outcome measures (e.g., measures of disease control)? The systems aren’t in place to get every patient to target! •Patients are getting regular planned interactions •Limited ability to intensify management of patients not meeting goals
  36. 36. What are the barriers? • QI efforts limited to “early adopters” • The hamster wheel • Belief in the quality of one’s practice – i.e. no meaningful measurement • Underdevelopment of practice team • Inability to access or use information technology or non- physician staff to improve patient care • Practice isolation • Fee-for-service reimbursement that doesn’t reward high quality care, in fact discourages it
  37. 37. If you could fully implement the Chronic Care Model: How would the care of your average chronically ill patient be different? How would their experience change?
  38. 38. If you could fully implement the Chronic Care Model: How would the day to day experience of the clinical staff be different? Do you think work satisfaction would change?
  39. 39. •www.improvingchroniccare.org Contact us: thanks
  40. 40. Self-Management Support and Community Resources Judith Schaefer, MPH MacColl Institute for Healthcare Innovation Center for Health Studies Group Health Cooperative Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation IHI National Forum December 10, 2007
  41. 41. 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
  42. 42. FACTS AND FICTIONSFACTS AND FICTIONS 1. Diabetes is the leading cause of adult blindness, amputations and kidney failure. True or false? ________________________________________________________________________________ A.A. False. Poorly controlled diabetes is the leading cause of adult blindness, amputations and kidney failure..
  43. 43. Setting the Stage for ChangeSetting the Stage for Change
  44. 44. Differences Between Acute and Chronic Conditions ACUTE CHRONIC Beginning Rapid Gradual Cause Usually one Many Duration Short Indefinite Diagnosis Commonly accurate Often uncertain Diagnostic tests Often decisive Often limited value Treatment Cure common Cure rare
  45. 45. Differences Between Acute and Chronic Care Roles ACUTE CHRONIC Role of Professional Select and conduct therapy Teacher/coac h and partner Role of Patient Lorig 2000 Follow orders Partner/ Daily manager
  46. 46. Symptom Cycle Vicious Cycle Disease Tense musclesFatigue Depression Anger/Frustration/Fear Stress/Anxiety
  47. 47. Persuasion TechniquesPersuasion Techniques • Agree that speaker should make the changeAgree that speaker should make the change • Explain why the change is importantExplain why the change is important • Warn of consequences of not changingWarn of consequences of not changing • AdviseAdvise speaker how to changehow to change • Reassure speaker that change is possibleReassure speaker that change is possible • Disagree if speaker argues against changeDisagree if speaker argues against change • Tell the speaker what to doTell the speaker what to do • Give examples of others (other patients, peers,Give examples of others (other patients, peers, celebrities) who have made similar healthy changescelebrities) who have made similar healthy changes
  48. 48. The Patient-Focused Approach • BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job. • KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management
  49. 49. Behavior Change StrategiesBehavior Change Strategies 1.1. Begin with your patient’s interestsBegin with your patient’s interests 2.2. Believe that your patient is motivated to live aBelieve that your patient is motivated to live a long, healthy lifelong, healthy life 3.3. Help your patient determine exactly what theyHelp your patient determine exactly what they might want to changemight want to change 4. Develop a reasonable, detailed action plan
  50. 50. Self-Management in office practice Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87 Personal Action Plan 1. List specific goals in behavioral terms 2. List barriers and strategies to address barriers 3. Specify Follow-up Plan 4. Share plan with practice team and patient’s social support ASSESS : Beliefs, Behavior & Knowledge ADVISE : Provide specific Information about health risks and benefits of change AGREE: Collaboratively set goals based on patient’s interest and confidence in their ability to change the behavior ASSIST : Identify personal barriers, strategies, problem- solving techniques and social/environmental support ARRANGE : Specify plan for follow-up (e.g., visits, phone calls, mailed reminders
  51. 51. Community Resources • Encourage patients to participate in effective community programs • Form partnerships with community organizations to support and develop interventions that fill gaps in needed services • Advocate for policies to improve care
  52. 52. Ecological Model of Health Behavior Community, Environment, Policy Systems, Organizations, Businesses Family, Friends Peer Groups Individual
  53. 53. Promotoras/Community Health Workers
  54. 54. Peer Led Workshops
  55. 55. Outreach
  56. 56. Organizations
  57. 57. Partnering Relationships networking coordinating cooperating collaborating resources commitment involvement
  58. 58. Environment and Policy
  59. 59. Walkable Neighborhoods/ Cyclovia
  60. 60. It Takes a Region
  61. 61. A Tour of the Model: Clinical Information Systems and Decision Support Brian Austin December 10 2007 Improving Chronic Illness Care is supported by The Robert Wood Johnson Foundation Grant # 48769 IHI National Forum December 10, 2007
  62. 62. The Care Model Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization You are here
  63. 63. Clinical Information Systems • 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.
  64. 64. Barriers to CIS use • Lack of perceived value • Competing business and productivity demands • Lack of office flow expertise • Lack of information support • Lack of leadership support
  65. 65. What is the Issue? Functionality! Whatever you use should be able to deliver information that supports: • population planning • clinical summaries at the visit • individual care planning • reminders • performance feedback
  66. 66. A Recent Product ComparisonA Recent Product Comparison CHCF’s Better Ideas Conference 2006CHCF’s Better Ideas Conference 2006
  67. 67. Necessary functions for chronic care • be organized by patient; not disease, but responsive to disease populations • contain data relevant to clinical practice • assist with internal and external performance reporting • guide clinical care first, measurement second!
  68. 68. Organizational characteristics of Medicare Managed Care Plans by Diabetes Quality Characteristic High performing Plans Low performing Plans P HbA1c >9.5 20% 49% Use of a Registry 78% 40% .02 Any Use of an EMR 50% 25% .11 Computerized Reminders 39% 5% .01 Fleming et al. Am J Managed Care 2004 10: 934
  69. 69. Modeling the Impacts of IT on Diabetes Quality: Changes from Baseline HbA1c SBP Cholesterol Disease Management - 0.24% - 5 mm -11 mg/dl Registries -0.50% - 1 mm - 31 mg/dl Decision Support -0.28% +4 mm -5 mg/dl Bu et al. Diabetes Care 2007; 30:1137
  70. 70. Keys to Success from Others That Have Implemented Registries • Everyone, including senior leadership understands the clinical utility and supports the time involved in upkeep. • Data forms are clear, data entry role is assigned, data review time allotted. • Data entered and retrieved are clinically relevant, and used for patient care first, and measurement second. • Data can be shared with patient to improve understanding of treatment plan.
  71. 71. Patient Expectations for Access to Their Records is Growing • 89% of respondents would like to be able to review their medical records. • Two-thirds would like electronic access, including 53% of Americans 60 and over • 91% think it is important to review what doctors write in their chart. • 84% would like to check for errors in their chart. Phone survey of 1,003 adults nationwide Nov. 2006 funded by Markle Foundation
  72. 72. A Patient View of an EMR
  73. 73. 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.
  74. 74. What is evidence-based medicine? • Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence. • The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments. McMaster University
  75. 75. Evidence-based practice • Customize guidelines to your setting • Embed in practice: able to influence real time decision-making Flow sheets with prompts Decision rules in EMR Share with patient Reminders in registry Standing orders • Have data to monitor care
  76. 76. Stepped Care • Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more) • First choice medication • Either increase dose or add second medication, and so on • Includes referral guideline
  77. 77. Going beyond consultation: integrating specialist expertise • Shared care agreements • Alternating primary-specialty visits • Joint visits • Roving expert teams • On-call specialist • Via nurse case manager
  78. 78. Effective educational methods Interactive, sequential opportunities in small groups or individual training • Academic detailing • Problem-based learning • Modeling (joint visits)
  79. 79. Effective educational methods • Build knowledge over time • Include all clinic staff • Involve changing practice, not just acquiring knowledge Evans et al, Pediatrics 1997;99:157
  80. 80. The Patient as Partner Principles of CIS &DS
  81. 81. Other Choices for Patient Decision Support PBGH Evaluation of Consumer Decision Support Tools June 2007
  82. 82. Ways to share guidelines with patients • Stoplight tools • Expectations for care • Wallet cards • Web sites • Workbooks
  83. 83. Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model
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  85. 85. Contact us:- 011-25464531, 9818569476 E-mail:- nursingnursing@yahoo.in
  86. 86. Thank you for attending

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