The Chronic Care Model provides a framework to improve care for patients with chronic illnesses. It emphasizes productive interactions between informed, activated patients and prepared practice teams. The model includes six core elements: community resources, self-management support, delivery system design, decision support, clinical information systems, and organized healthcare systems. Studies show practices that more fully implement the model through interventions experience improved quality of care and patient outcomes. Randomized controlled trials demonstrate the Chronic Care Model is effective across different chronic conditions. While implementation presents challenges, the evidence indicates the Chronic Care Model can successfully redesign care for chronic illness.
The document provides information on palliative care, including:
- Palliative care aims to improve quality of life and relieve suffering for patients with life-limiting illnesses and their families.
- It focuses on pain management and other symptom relief without hastening or postponing death.
- Palliative care is appropriate at any stage of illness and can be provided alongside curative treatment.
The document provides an introduction to palliative care and a holistic approach. It defines palliative care according to the WHO as improving quality of life for patients facing life-threatening illness through preventing and relieving suffering. Key principles of palliative care discussed include taking a holistic, patient-centered approach and using a multidisciplinary team. Factors affecting provision of palliative care and strategies for improving services are also outlined.
Palliative care aims to improve quality of life and reduce suffering for those with serious illnesses through early identification and treatment of pain and other distressing symptoms. It can be provided in hospitals, outpatient clinics, homes, and hospice centers using an interdisciplinary team approach. While palliative care and hospice care both focus on comfort, palliative care can be provided at any stage of illness and with curative treatment, whereas hospice care is for those with less than 6 months to live who are no longer pursuing curative options. Barriers to palliative care include lack of awareness, competency and funding as well as consumer fears and delays in diagnosis.
Palliative care aims to improve quality of life for patients with serious illnesses through pain and symptom management as well as addressing physical, psychological, social, and spiritual needs. It focuses on preventing and relieving suffering for the patient and their family from diagnosis through the end of life and into bereavement. Palliative care is provided through interdisciplinary teams in various settings including hospitals, outpatient clinics, nursing homes, and in the community.
Palliative care focuses on reducing the intensity and severity of symptoms from disease to improve quality of life. It is provided by an interdisciplinary team and addresses physical, emotional, and spiritual needs through pain and symptom management. Palliative care can be provided alongside curative treatment from the time of diagnosis for diseases like cancer, organ failure, Alzheimer's, and AIDS. Radiotherapy can help manage bone metastases, spinal cord compression, and other symptoms in palliative care.
A chronic condition is a disease or illness that lasts for a long time or recurs frequently. Common chronic diseases include arthritis, asthma, cancer, diabetes, and some viral diseases. Chronic conditions are distinguished from acute conditions by affecting multiple body systems long-term and not being fully responsive to treatment. They may involve periods of remission or relapse. Chronic conditions can hinder independence and create additional limitations. Lifestyle factors like diet, exercise, not smoking, and limiting alcohol can help prevent or manage chronic diseases.
The document provides information on palliative care, including:
- Palliative care aims to improve quality of life and relieve suffering for patients with life-limiting illnesses and their families.
- It focuses on pain management and other symptom relief without hastening or postponing death.
- Palliative care is appropriate at any stage of illness and can be provided alongside curative treatment.
The document provides an introduction to palliative care and a holistic approach. It defines palliative care according to the WHO as improving quality of life for patients facing life-threatening illness through preventing and relieving suffering. Key principles of palliative care discussed include taking a holistic, patient-centered approach and using a multidisciplinary team. Factors affecting provision of palliative care and strategies for improving services are also outlined.
Palliative care aims to improve quality of life and reduce suffering for those with serious illnesses through early identification and treatment of pain and other distressing symptoms. It can be provided in hospitals, outpatient clinics, homes, and hospice centers using an interdisciplinary team approach. While palliative care and hospice care both focus on comfort, palliative care can be provided at any stage of illness and with curative treatment, whereas hospice care is for those with less than 6 months to live who are no longer pursuing curative options. Barriers to palliative care include lack of awareness, competency and funding as well as consumer fears and delays in diagnosis.
Palliative care aims to improve quality of life for patients with serious illnesses through pain and symptom management as well as addressing physical, psychological, social, and spiritual needs. It focuses on preventing and relieving suffering for the patient and their family from diagnosis through the end of life and into bereavement. Palliative care is provided through interdisciplinary teams in various settings including hospitals, outpatient clinics, nursing homes, and in the community.
Palliative care focuses on reducing the intensity and severity of symptoms from disease to improve quality of life. It is provided by an interdisciplinary team and addresses physical, emotional, and spiritual needs through pain and symptom management. Palliative care can be provided alongside curative treatment from the time of diagnosis for diseases like cancer, organ failure, Alzheimer's, and AIDS. Radiotherapy can help manage bone metastases, spinal cord compression, and other symptoms in palliative care.
A chronic condition is a disease or illness that lasts for a long time or recurs frequently. Common chronic diseases include arthritis, asthma, cancer, diabetes, and some viral diseases. Chronic conditions are distinguished from acute conditions by affecting multiple body systems long-term and not being fully responsive to treatment. They may involve periods of remission or relapse. Chronic conditions can hinder independence and create additional limitations. Lifestyle factors like diet, exercise, not smoking, and limiting alcohol can help prevent or manage chronic diseases.
This document discusses palliative care, including its definition, aims, models, barriers to development, and challenges in Indonesia. Some key points include:
- Palliative care aims to relieve suffering and improve quality of life for patients with life-limiting illnesses through pain and symptom management as well as psychological, social, and spiritual support.
- Barriers to palliative care development include lack of funding, opioid availability issues, public and government awareness, and education/training programs.
- Palliative care in Indonesia is developing but still faces challenges related to policy, education, attitudes, and social conditions. It is primarily available in major cities near cancer treatment centers.
- Effective palliative care requires an inter
The document discusses the history and definitions of health promotion. It provides:
1) The term "health promotion" was first used in 1974 and refers to strategies that tackle the wider determinants of health beyond just healthcare.
2) Health promotion aims to empower people to have more control over their health and aspects of their lives that affect it.
3) Key strategies of health promotion include building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services.
Mental Health and Psychosocial Support in Emergencies CORE Group
This document provides an overview of mental health and psychosocial support (MHPSS) in emergency settings according to International Medical Corps. It discusses what MHPSS is, common needs in emergencies, and International Medical Corps' MHPSS programs and interventions. MHPSS aims to promote psychosocial well-being and prevent or treat mental disorders. It outlines their MHPSS intervention pyramid and programs including needs assessments, integrating mental health into general healthcare, early childhood development, and peer support programs. Guidelines and tools for MHPSS in emergencies are also mentioned.
Monitoring and Evaluation of Health ServicesNayyar Kazmi
This document provides an overview of monitoring and evaluation (M&E) of health services. It discusses the key differences between monitoring and evaluation, and explains that M&E is important to assess whether health programs and services are achieving their goals and objectives. The document also outlines the main components and steps involved in conducting evaluations, including developing indicators, collecting and analyzing data, reporting findings, and implementing recommendations.
This document discusses concepts of wellness and well-being. It defines well-being as having both objective and subjective components. The objective components are standard of living and level of living. Standard of living is defined by factors like income, housing, and access to services. Level of living includes nine factors like health, food, education, and recreation. The subjective component is quality of life, which is an individual's perception of their physical, mental, and social well-being based on satisfaction with areas of life. Governments aim to improve citizens' quality of life through better health, education, and social services.
The document discusses the World Health Organization's goal of "Health for All" by the year 2000. It was established in 1977 with the aim of attaining a basic level of health that allows people to live productive lives. The strategy involved strengthening primary healthcare infrastructure at the village, sub-center, primary health center, and community health center levels. It also outlined a primary healthcare package and specific health goals for India to reduce mortality and birth rates while increasing life expectancy. The national strategy for achieving Health for All built upon the principles of primary healthcare established at Alma-Ata in 1978.
Palliative care aims to improve quality of life for patients facing life-limiting illnesses through comprehensive pain and symptom management as well as psychosocial and spiritual support. It can be provided alongside curative treatment or as the main focus of care. The goals are to prevent and relieve suffering through early identification of issues, addressing physical, psychological, social and spiritual needs using a multidisciplinary team approach. Palliative care strives to help patients and their families cope with illness and bereavement.
The document discusses the determinants of health, which are defined as the conditions that influence individual and population health, including social, economic, cultural, environmental and lifestyle factors. It outlines the key components of determinants, including socioeconomic status, living/working conditions, social support networks, and individual factors. The document explains why understanding determinants of health is important for public health efforts aimed at health promotion and disease prevention.
Chronic illnesses are health conditions that last over six months. Examples include cancer, heart disease, and arthritis. Factors that contribute to chronic illnesses include heredity, lifestyle, and environment. People with chronic illnesses have ongoing needs related to employment, financial support, health care, housing, and self-esteem. Their socioeconomic status, age, and any disabilities can impact their ability to access resources to manage their condition.
This document provides an introduction to community and community health concepts. It defines a community as a social group within geographical boundaries that interacts and shares common values. A community has defined roles and functions for its members. Community health refers to the health status, problems, and care provided to the whole community. The objectives of community health are to promote health, diagnose and treat diseases early, and control disability through organized community efforts. Community health nursing aims to empower communities to improve health through education and programs tailored to their needs and resources.
This document outlines a presentation on Roy's Adaptation Model of nursing. It begins with ground rules for the presentation and objectives. It then provides an introduction to the model and biographical information about creator Callista Roy. The core components of the model are defined, including its metaparadigm concepts, types of stimuli, coping mechanisms, adaptive modes, and assumptions. Applications of the model in various areas like education, administration, and practice are described. Strengths and weaknesses are identified. The document concludes with an example of implementing the model for a patient with rheumatoid arthritis.
This document discusses various concepts related to health and disease. It begins by outlining four concepts of health: biomedical, ecological, psychosocial, and holistic. It then examines definitions of health from sources like Webster and WHO. Key aspects of health discussed include its multidimensional nature, determinants, indicators, and spectrum. The document also covers concepts of disease causation using the epidemiological triad model, as well as the host, agent, and environment. Other topics summarized are natural history of disease, levels of prevention, and disease control, elimination and eradication.
The document discusses the importance of addressing spirituality in health and illness. It notes that modern medicine has focused more on technology than caring for the whole person, including their physical, emotional, social and spiritual needs. Research shows strong connections between spirituality/religious practices and better health outcomes like coping with illness, recovery from surgery, and immune system functioning. The document advocates taking a spiritual history as part of patient care and addressing spiritual issues compassionately with patients.
an individual’s perception of their position in life in the context of the cultural and value systems in which they live and in relation to their goals, expectations, standards and concerns
The document discusses indicators used to assess the health status of a community. It provides definitions of key terms like health, illness, disease, and wellness. It also defines indicators and discusses characteristics of good indicators. The document categorizes indicators as quantitative and qualitative. It describes hierarchies of indicators and provides examples of common indicators used to measure mortality, morbidity, disability rates, nutritional status, health care delivery, utilization rates, social and mental health, the environment, socioeconomics, health policies, and quality of life.
Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
The document discusses end-of-life care, including palliative care, hospice care, and spiritual care. It defines end-of-life care as care for patients with advanced, progressive, and incurable conditions. The goals of end-of-life care are to provide comfort, improve quality of life, and ensure a dignified death. Palliative care focuses on relieving suffering and improving quality of life for patients with serious illnesses, while hospice care provides support to terminally ill patients and their families. Nurses play a key role in providing holistic care to address physical, emotional, and spiritual needs at the end of life.
This document provides an introduction to palliative nursing care. It defines palliative care as an approach that improves quality of life for patients with life-threatening illnesses through pain management and treatment of physical, psychosocial, and spiritual problems. Palliative care aims to prevent and relieve suffering. It has developed since the 1960s in the UK and US and is now integrated into health care systems worldwide. Palliative care can benefit those with advanced diseases, uncertain medical goals, or end-of-life care needs. Effective palliative care is patient-centered, family-supported, communicates effectively, and works with an interdisciplinary team. Barriers to palliative care include cultural views of death and lack of understanding, knowledge, communication skills
This document discusses chronic illness management. It defines a chronic illness as a condition lasting 3 months or longer that can be unpredictable. Common chronic illnesses include heart disease, cancer, diabetes and arthritis. Risk factors include behaviors like smoking, poor diet and lack of exercise, as well as genetic predisposition. Chronic diseases account for most American deaths each year. Health psychology examines the biological, psychological and social factors related to illness and health. Clinical health psychologists help patients manage chronic conditions through cognitive and behavioral therapies.
This document discusses palliative care, including its definition, aims, models, barriers to development, and challenges in Indonesia. Some key points include:
- Palliative care aims to relieve suffering and improve quality of life for patients with life-limiting illnesses through pain and symptom management as well as psychological, social, and spiritual support.
- Barriers to palliative care development include lack of funding, opioid availability issues, public and government awareness, and education/training programs.
- Palliative care in Indonesia is developing but still faces challenges related to policy, education, attitudes, and social conditions. It is primarily available in major cities near cancer treatment centers.
- Effective palliative care requires an inter
The document discusses the history and definitions of health promotion. It provides:
1) The term "health promotion" was first used in 1974 and refers to strategies that tackle the wider determinants of health beyond just healthcare.
2) Health promotion aims to empower people to have more control over their health and aspects of their lives that affect it.
3) Key strategies of health promotion include building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services.
Mental Health and Psychosocial Support in Emergencies CORE Group
This document provides an overview of mental health and psychosocial support (MHPSS) in emergency settings according to International Medical Corps. It discusses what MHPSS is, common needs in emergencies, and International Medical Corps' MHPSS programs and interventions. MHPSS aims to promote psychosocial well-being and prevent or treat mental disorders. It outlines their MHPSS intervention pyramid and programs including needs assessments, integrating mental health into general healthcare, early childhood development, and peer support programs. Guidelines and tools for MHPSS in emergencies are also mentioned.
Monitoring and Evaluation of Health ServicesNayyar Kazmi
This document provides an overview of monitoring and evaluation (M&E) of health services. It discusses the key differences between monitoring and evaluation, and explains that M&E is important to assess whether health programs and services are achieving their goals and objectives. The document also outlines the main components and steps involved in conducting evaluations, including developing indicators, collecting and analyzing data, reporting findings, and implementing recommendations.
This document discusses concepts of wellness and well-being. It defines well-being as having both objective and subjective components. The objective components are standard of living and level of living. Standard of living is defined by factors like income, housing, and access to services. Level of living includes nine factors like health, food, education, and recreation. The subjective component is quality of life, which is an individual's perception of their physical, mental, and social well-being based on satisfaction with areas of life. Governments aim to improve citizens' quality of life through better health, education, and social services.
The document discusses the World Health Organization's goal of "Health for All" by the year 2000. It was established in 1977 with the aim of attaining a basic level of health that allows people to live productive lives. The strategy involved strengthening primary healthcare infrastructure at the village, sub-center, primary health center, and community health center levels. It also outlined a primary healthcare package and specific health goals for India to reduce mortality and birth rates while increasing life expectancy. The national strategy for achieving Health for All built upon the principles of primary healthcare established at Alma-Ata in 1978.
Palliative care aims to improve quality of life for patients facing life-limiting illnesses through comprehensive pain and symptom management as well as psychosocial and spiritual support. It can be provided alongside curative treatment or as the main focus of care. The goals are to prevent and relieve suffering through early identification of issues, addressing physical, psychological, social and spiritual needs using a multidisciplinary team approach. Palliative care strives to help patients and their families cope with illness and bereavement.
The document discusses the determinants of health, which are defined as the conditions that influence individual and population health, including social, economic, cultural, environmental and lifestyle factors. It outlines the key components of determinants, including socioeconomic status, living/working conditions, social support networks, and individual factors. The document explains why understanding determinants of health is important for public health efforts aimed at health promotion and disease prevention.
Chronic illnesses are health conditions that last over six months. Examples include cancer, heart disease, and arthritis. Factors that contribute to chronic illnesses include heredity, lifestyle, and environment. People with chronic illnesses have ongoing needs related to employment, financial support, health care, housing, and self-esteem. Their socioeconomic status, age, and any disabilities can impact their ability to access resources to manage their condition.
This document provides an introduction to community and community health concepts. It defines a community as a social group within geographical boundaries that interacts and shares common values. A community has defined roles and functions for its members. Community health refers to the health status, problems, and care provided to the whole community. The objectives of community health are to promote health, diagnose and treat diseases early, and control disability through organized community efforts. Community health nursing aims to empower communities to improve health through education and programs tailored to their needs and resources.
This document outlines a presentation on Roy's Adaptation Model of nursing. It begins with ground rules for the presentation and objectives. It then provides an introduction to the model and biographical information about creator Callista Roy. The core components of the model are defined, including its metaparadigm concepts, types of stimuli, coping mechanisms, adaptive modes, and assumptions. Applications of the model in various areas like education, administration, and practice are described. Strengths and weaknesses are identified. The document concludes with an example of implementing the model for a patient with rheumatoid arthritis.
This document discusses various concepts related to health and disease. It begins by outlining four concepts of health: biomedical, ecological, psychosocial, and holistic. It then examines definitions of health from sources like Webster and WHO. Key aspects of health discussed include its multidimensional nature, determinants, indicators, and spectrum. The document also covers concepts of disease causation using the epidemiological triad model, as well as the host, agent, and environment. Other topics summarized are natural history of disease, levels of prevention, and disease control, elimination and eradication.
The document discusses the importance of addressing spirituality in health and illness. It notes that modern medicine has focused more on technology than caring for the whole person, including their physical, emotional, social and spiritual needs. Research shows strong connections between spirituality/religious practices and better health outcomes like coping with illness, recovery from surgery, and immune system functioning. The document advocates taking a spiritual history as part of patient care and addressing spiritual issues compassionately with patients.
an individual’s perception of their position in life in the context of the cultural and value systems in which they live and in relation to their goals, expectations, standards and concerns
The document discusses indicators used to assess the health status of a community. It provides definitions of key terms like health, illness, disease, and wellness. It also defines indicators and discusses characteristics of good indicators. The document categorizes indicators as quantitative and qualitative. It describes hierarchies of indicators and provides examples of common indicators used to measure mortality, morbidity, disability rates, nutritional status, health care delivery, utilization rates, social and mental health, the environment, socioeconomics, health policies, and quality of life.
Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
The document discusses end-of-life care, including palliative care, hospice care, and spiritual care. It defines end-of-life care as care for patients with advanced, progressive, and incurable conditions. The goals of end-of-life care are to provide comfort, improve quality of life, and ensure a dignified death. Palliative care focuses on relieving suffering and improving quality of life for patients with serious illnesses, while hospice care provides support to terminally ill patients and their families. Nurses play a key role in providing holistic care to address physical, emotional, and spiritual needs at the end of life.
This document provides an introduction to palliative nursing care. It defines palliative care as an approach that improves quality of life for patients with life-threatening illnesses through pain management and treatment of physical, psychosocial, and spiritual problems. Palliative care aims to prevent and relieve suffering. It has developed since the 1960s in the UK and US and is now integrated into health care systems worldwide. Palliative care can benefit those with advanced diseases, uncertain medical goals, or end-of-life care needs. Effective palliative care is patient-centered, family-supported, communicates effectively, and works with an interdisciplinary team. Barriers to palliative care include cultural views of death and lack of understanding, knowledge, communication skills
This document discusses chronic illness management. It defines a chronic illness as a condition lasting 3 months or longer that can be unpredictable. Common chronic illnesses include heart disease, cancer, diabetes and arthritis. Risk factors include behaviors like smoking, poor diet and lack of exercise, as well as genetic predisposition. Chronic diseases account for most American deaths each year. Health psychology examines the biological, psychological and social factors related to illness and health. Clinical health psychologists help patients manage chronic conditions through cognitive and behavioral therapies.
This document discusses concepts related to illness, disease, and chronic conditions. It defines illness as a personal state of feeling unwell compared to previous functioning, while disease refers to biological or physiological abnormalities. Chronic conditions require long-term management and do not resolve spontaneously. The document outlines various factors that influence disease risk, common causes of disease, classifications of disease, and terminology used in understanding health conditions. It also discusses the effects of illness on individuals and families.
Chronic illnesses like heart disease, cancer, stroke, COPD, and diabetes are generally incurable and worsen over time. They are the major causes of death and health care costs in the US. Risky behaviors in youth and middle age such as smoking, poor diet, physical inactivity, obesity, and alcohol abuse put people at higher risk of developing chronic conditions. Adopting a healthy lifestyle through not smoking, eating well, exercising regularly, and limiting alcohol can help prevent chronic diseases and reduce their impact on one's health as they age.
This presentation discusses chronic disease management in older adults. Chronic disease management aims to address chronic illnesses in an integrated and cost-effective way to achieve the best patient outcomes. Eighty percent of older adults have at least one chronic disease. The nursing process can be used to support patient self-management of chronic diseases through assessment, diagnosis, goal-setting, implementation, and evaluation. Setting SMART goals and providing education are keys to effective chronic disease management.
This document provides information and advice for coping with chronic illness. It discusses the importance of acceptance, maintaining a positive attitude, taking control through education and active participation in treatment, building support networks, managing stress, addressing potential depression or anxiety, quitting smoking if applicable, and finding appropriate resources and support groups.
This document provides tips and advice for developing and maintaining good relationships, especially for senior citizens. Some key points include:
1) Relationship building is complex and requires understanding others, cultivating equality, and remembering that we are all temporary guests in this world.
2) People may enter your life for a reason, season, or lifetime, so it's important to understand the nature and purpose of different relationships.
3) Developing good relationships as a senior citizen depends on factors like financial independence, living situation, and relationship with family members.
4) Tips are provided for maintaining good relationships with family, managing finances, avoiding conflicts, and reducing stress in old age. Understanding past behaviors and managing expectations
This document provides an overview of a workshop on tools for temperance and self-management. The workshop covers what disease is, the differences between acute and chronic disease, self-management strategies including temperance and self-control, self-management tasks, tools for self-management, ground rules for the workshop, and an introduction activity where participants share about their health conditions. Participants then learn about the power of the mind and creating short-term SMART action plans to work on specific behaviors.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Dr Eileen Pepler, Academic, Researcher and Consultant in the Canadian Healthcare will discuss how NHS England work in chronic disease is being translated into a Canadian context.
Parsons developed the sick role model in the 1950s to describe illness as a temporary, medically sanctioned form of deviant behavior. Key aspects of the model include that the sick are excused from normal duties if they seek medical advice and comply with treatment. The model draws on Freudian concepts like the doctor-patient relationship resembling a parent-child dynamic. While influential, criticisms of the model include that it does not consider power imbalances between doctors and patients or account for chronic illness. However, the sick role model still provides a framework for cross-cultural comparisons of how societies view deviant behavior and time away from duties.
The document summarizes a presentation on organizing health information in an eHealth environment according to citizen-centric principles and concepts. It outlines the background, methods, preliminary findings, conceptual information model, information management principles, and roadmap presented. The presentation calls for an iterative development process to involve stakeholders and promote a citizen-centric model for integrating new eHealth possibilities in New Zealand's health systems.
Presentation: Providing Hospice Care in a Skilled or Long-Term Care Nursing F...AliveHospice
The document discusses hospice care provided in skilled nursing facilities. It provides an overview of hospice philosophy, care goals of comfort and dignity. Hospice services include management of pain and symptoms by an interdisciplinary team. The partnership between hospice agencies and nursing facilities aims to provide comprehensive end of life care through open communication and coordinated care planning.
The document discusses sociological perspectives on health and illness, including functionalist and interactionist views. It outlines Parsons' concept of the "sick role" which assigns rights and responsibilities to those who are ill. Specifically, the sick have a right to exemption from normal duties but also an obligation to seek treatment and get well. However, interactionists argue the sick role is more complex, with illness labels influencing how people see themselves and are treated by others. Being labeled sick can lead to negative self-concepts and interactions.
Hearing loss is the third most common chronic disability. Approximately 9 out of 10 deaf children are born to hearing parents. There is an estimated 1 million people in India with profound hearing loss, and over 2 million with severe to moderate hearing loss. Hearing impairments have historically denied people legal rights and access to education. Early detection of hearing loss in children is important to prevent delays in speech development. Common causes of conductive hearing loss include fluid, infections, and cholesteatoma. Treatment options depend on the type of hearing loss and include surgical procedures, hearing aids, bone anchored hearing aids, and cochlear implants.
This document provides information on counseling older adults. It discusses trends in the aging US and Wisconsin populations. Issues addressed include ageism, elder abuse/neglect, vocational transitions, mental deterioration, sexuality, substance abuse, depression, and resources. Statistics and research are presented on each topic. Implications for counseling are discussed, such as being aware of physical and cognitive limitations, addressing stereotypes, and recognizing depression is not a normal part of aging. The document aims to educate counselors working with older adult clients.
Media for Social Responsibility: Portrayals of Disability and Chronic Illness...Anthony Adornato
Seminar focusing on media portrayals of people with disability and chronic illness. For presentations of other speakers, visit: Great line-up of experts for my course on portrayals of disability and chronic illness in the media. Access the presentations here: http://bit.ly/2cGHT1f
The document discusses renal disease and renal failure in dogs. It defines key terms like renal disease, renal failure, azotemia and uremia. Renal failure can be acute or chronic. Acute renal failure is a sudden reduction in renal function while chronic renal failure is a relatively common syndrome in older dogs representing the end stage of various renal diseases. The document outlines the causes, clinical signs, diagnosis, and management of both acute and chronic renal failure in dogs. It also lists some breeds that are prone to developing renal failure.
Dr. Merle Mishel developed the Uncertainty in Illness Theory and the Mishel Uncertainty in Illness Scale. She earned degrees including a PhD in social psychology. Her theory proposes that uncertainty is caused by antecedents like stimuli and cognitive capacities, and is appraised through danger, inference, or opportunity. Coping strategies like mobilizing or buffering are used to adjust to uncertainty. The theory aims to help measure uncertainty and identify ways to improve patient coping and adaptation. It has been applied in nursing research and practice areas like cancer.
Leveraging Healthcare Analytics to Reduce Heart Failure Readmission Rates Health Catalyst
Heart failure patients are adding an enormous strain to the US healthcare system. In addition, readmission rates for these diseases are adding to the burden. Healthcare analytics can play a key role. By following these 4 steps, all of which include data analytics, health systems can begin to reduce readmission rates: 1) Understand your true admission rates. 2) Establish reliable baseline measures. 3) Be aware of balance measures. 4) Establish an EDW.
This document summarizes the proceedings of an advisory panel meeting to discuss potential research topics for improving healthcare systems and patient outcomes. It provides an overview of the Patient-Centered Outcomes Research Institute's (PCORI) mission to fund research that discovers new information, allows for better decision making, and leads to better patient outcomes. Key areas of focus for potential research include care for chronic conditions, cancer, palliative care, pregnancy, and patients with multiple chronic conditions. The document discusses criteria for prioritizing research topics and provides brief summaries of 15 potential research topics for the advisory panel to review and rate.
The document discusses chronic care and the chronic care model. It notes that while 55% of people have no chronic conditions, those with chronic conditions account for the majority of health care visits, admissions, days in the hospital, and prescriptions. The chronic care model emphasizes a system-wide approach rather than just physician behavior, and includes elements like self-management support, delivery system design, decision support, clinical information systems, and community resources. Productive interactions between prepared practice teams and informed, activated patients are key. Payment issues around chronic care include how to pay providers for new services and share savings from reduced utilization.
Team as Treatment: Driving Improvement in DiabetesCHC Connecticut
Team-based care has been shown to improve outcomes for patients with diabetes compared to conventional care. Key members of the diabetes care team include nurses, registered dietitians, pharmacists, and community health workers. Technologies like telehealth, electronic health records, and dashboards help coordinate care and monitor patient populations. Community programs also support diabetes patients through services like the YMCA's diabetes prevention program.
Academy Health- Annual Research Meeting - State Policy Interest Groups- 2013scherala
The document summarizes findings from a study evaluating the impact of the Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) on clinical quality measures at the midpoint of the initiative. The study found that three measures showed statistically significant improvement from baseline to 21 months: screening diabetic patients for depression, developing asthma action plans for children with persistent asthma, and developing care plans for highest risk patients. While other measures trended toward improvement or no change, the results indicate that primary care practice transformation takes time but processes of care are more likely to improve before outcomes. The initiative provides an example of using clinical quality measures to evaluate the impact of implementing patient-centered medical home processes and improving patient care.
How to Define Effective and Efficient Real World TrialsTodd Berner MD
This document discusses strategies for designing effective and efficient real-world clinical trials. It covers topics such as using real-world evidence to inform clinical trial design, the differences between efficacy and effectiveness, challenges around representativeness in trial populations, and the value of pragmatic clinical trials. It also discusses leveraging electronic health records for condition-specific prompts and clinical decision support to improve performance and quality of care.
How to design effective and efficient real world trials TB Evidence 2014 10.2...Todd Berner MD
This document discusses strategies for designing effective and efficient real-world clinical trials. It covers topics such as using real-world evidence to inform clinical trial design, the differences between efficacy and effectiveness, challenges in defining quality metrics, and strategies for improving performance within healthcare systems. The document provides information on pragmatic clinical trials and how real-world evidence could reduce costs compared to traditional clinical trials.
Paying for performance to improve the delivery of health interventions in LMICsReBUILD for Resilience
This presentation from Sophie Witter & Karin Diaconu of Queen Margaret University, UK outlines the findings from a Cochrane review undertaken by the team on paying for performance to improve the delivery of health interventions in low and middle-income countries.
This document summarizes the current state of evidence for personal connected health technologies. It finds that while many technologies and interventions are being studied, the evidence base remains limited due to small study sizes, industry sponsorship, and a lack of standardized research methodologies. Recommendations include increasing study sizes, developing consensus guidelines for research in this field, and further validating apps and devices through comparative studies to help address current evidence gaps.
This lecture discusses patient-centered care and behavior change strategies. It describes patient-centered care as care that is respectful of individual patient needs and values. The lecture notes that government policy and payers are increasingly focused on patient engagement and value-based care. Research shows patient-centered care can improve outcomes and lower costs when it includes patient-oriented behavior change interventions. The lecture provides an overview of best practices for behavior change strategies to increase patient engagement.
The document outlines a quality improvement project conducted by a team at an Accountable Care Organization to improve hypertension control rates in their patient population. It describes forming a multidisciplinary team, analyzing the root causes of uncontrolled hypertension through tools like cause-and-effect diagrams, and implementing a Plan-Do-Study-Act cycle to test engaging patients in self-management education during visits. The team's goal is to increase the percentage of hypertensive patients with controlled blood pressure below 140/90 mmHg through standardized communication of management strategies.
The document outlines a quality improvement project conducted by a team at an Accountable Care Organization to improve hypertension control rates in their patient population. It describes forming a multidisciplinary team, analyzing the root causes of uncontrolled hypertension through tools like cause-and-effect diagrams, and implementing a Plan-Do-Study-Act cycle to test engaging patients in self-management education during visits. The team's goal is to increase the percentage of hypertensive patients with controlled blood pressure below 140/90 mmHg through standardized communication of management strategies.
American Public Health Association- Annual Meeting 2014 Presentation scherala
Title: Using Quantitative Data to focus Medical Home Facilitation Interventions in the Massachusetts Patient Centered Medical Home Initiative (MA PCMHI)
This document summarizes a presentation on physician assessment and retraining through a collaboration between the KSTAR program and JPS Health Network. It provides background on physician re-entry to practice after an absence, outlines the KSTAR assessment process and mini-residency program at JPS, and shares demographic data and outcomes of the first 28 physicians who completed the program. The collaboration uses a comprehensive assessment to determine physicians' needs and place them in a 3-month mini-residency to address areas for improvement before returning to unrestricted practice. Most physicians are able to complete the program successfully and return to patient care.
This survey of hospitalists in British Columbia found that they perceive having more time with patients, improved access to nursing and allied health staff, and better interprofessional teamwork and communication as the most effective quality improvement strategies. Hospitalists indicated that lack of time, lack of QI training, and lack lack of performance data were the top barriers to participation in QI initiatives. Factors such as years of experience as a hospitalist, work status, annual weeks worked, patient volume per day, and formal QI training were found to impact hospitalists' involvement in QI.
Apresentação realizada no I Seminário Internacional de Atenção às Condições Crônicas, pela diretora do Programa da Gestão de Doenças Crônica dos Serviços Sanitários De Alberta/Canadá, Sandra Delon.
Belo Horizonte, 11 de novembro de 2014
The document discusses evidence based healthcare and the process of evidence based medicine. It describes the 5 step process as asking questions, acquiring information, appraising the quality of evidence, applying the results, and assessing performance. Simple skills can help focus questions and basic rules can improve ability to critique literature. Simple math, not complex statistics, can help clearly describe study results.
This document outlines concepts related to health care quality assessment. It describes key definitions, such as quality referring to services that increase health outcomes and are consistent with current knowledge. It also discusses perspectives on quality from practitioners, patients, and communities. Additionally, the document outlines different levels of quality analysis from national policies to individual care provision and lists examples of common quality indicators assessed in the US, such as patient satisfaction, mortality rates, and adherence to treatment protocols.
An outbreak of chikungunya virus has spread like an epidemic in the capital city this year, with doctors seeing many young patients suffering from acute joint pain wheelchair bound. While only a few labs can test for the virus, it is estimated that 80% of patients presenting with viral fever and joint pain symptoms at some hospitals have tested positive for chikungunya. The outbreak has been attributed to increased mosquito breeding due to heavy monsoon rains. Treatment involves painkillers, though paracetamol often provides little relief from the debilitating joint pain associated with the illness.
Your plastic water bottle could be as dirty as your toiletNursing Hi Nursing
Researchers tested four types of reusable water bottles and found that bottles that were used for a week without washing had more bacteria than a toilet seat. Specifically, the slide-top bottle had more bacteria than an average toilet seat, pet bowl, or kitchen sink. Over 60% of the bacteria found on the bottles could make people sick. The cleanest bottle type tested was the straw-top bottle, and researchers also found that stainless steel bottles were healthier options than plastic bottles.
This document provides information and strategies for sun safety at resorts. It discusses establishing a sun safety program called "Go Sun Smart" that would provide education materials to guests and training to employees. The program is based on over a decade of sun safety research focusing on outdoor workers and recreationists. The document then covers the skin cancer problem, the effects of UV radiation, assessing personal risk factors, and practicing sun safety strategies like using shade, covering up with protective clothing and sunglasses, and applying sunscreen. It emphasizes the importance of monitoring UV levels and reapplying sunscreen regularly.
The document discusses various topics related to transport operations and ambulance services including emergency vehicle design, checking ambulances, ambulance equipment, driving techniques, incident response, transporting patients, and air medical transports. It provides information on setting up landing zones and transferring patients safely. National EMS education standard competencies are also listed that cover operations, transport safety, medicine, infectious diseases and more.
This document provides information and strategies for sun safety at resorts. It discusses establishing a sun safety program called "Go Sun Smart" that would provide education materials to guests and training to employees. The program is based on over a decade of sun safety research focusing on outdoor workers and recreationists. The document then covers topics like the skin cancer problem, how UV radiation affects skin, assessing personal risk factors, and practicing sun safety strategies like using shade, covering up with protective clothing, and applying sunscreen properly. It emphasizes the importance of early skin cancer detection.
Pizza shops and steakhouses that use charcoal or wood burners produce significant emissions and damage the environment in major cities like Sao Paulo, Brazil. A study found emissions from thousands of pizza shops and domestic waste burning contribute to Sao Paulo's air pollution problems despite its green vehicle policies. While vehicles use cleaner biofuels, emissions from over 800 pizza shops using wood burning stoves daily and over 1,000 pizzas produced for home delivery weekly on wood burning stoves negate some of the environmental benefits.
The document discusses the effects of marijuana use and abuse. It defines marijuana and how it is consumed. It outlines short-term effects like rapid heart rate and long-term effects on the brain, lungs and other organs. Signs of addiction and dependency are provided. Treatment typically involves detoxification and support to reintegrate into society. Myths about marijuana are debunked, such as it being safe because it is a plant. The summary emphasizes that marijuana is harmful and can isolate users from society, and that treatment requires holistic social support.
Bill Gates says that genetically modified mosquitoes may be used to fight malaria within the next five years. Researchers are using a gene editing technique called a "gene drive" to alter mosquitoes so they are resistant to diseases like malaria and dengue. Gates believes this technology could dramatically reduce malaria deaths by suppressing mosquito populations. However, some scientists have raised concerns that unintended mutations in released mosquitoes could have unknown consequences.
A study from the University of Manchester found that frequent childhood moves, especially during early adolescence, are linked to higher risks of negative outcomes in adulthood such as suicide attempts, criminal violence, mental illness, substance abuse, and premature death. The researchers collected data on all people born in Denmark from 1971 to 1997, documenting every residential move from birth to age 14, and correlated subsequent adverse events in adulthood.
An international team of scientists reviewed 19 previous studies involving 68,000 elderly people and found no link between high cholesterol levels and heart disease in those over 60 years old. The study suggests that 92% of elderly people with high cholesterol lived as long or longer than those with low cholesterol. The authors call for a reevaluation of statin prescriptions for the elderly, but their findings have been criticized by other academics who question the research methods. Some experts say that as people age, many other factors impact health, making the effects of high cholesterol less clear.
India has seen a decline in childhood stunting but now faces rising issues with diabetes and being overweight. The number of diabetics in India is projected to increase to over 100 million in the next 15 years. While India has made progress against undernutrition, public health policies now need to also address the growing problems of overnutrition and diabetes. Non-communicable diseases like heart disease also place a large economic burden on Indian families.
Scientists have developed the world's first vaccine for Toxic Shock Syndrome (TSS), a severe circulatory and organ failure caused by bacterial toxins from Staphylococcus bacteria. The vaccine was successfully tested in a Phase I trial. TSS, also known as "tampon disease", often affects young women using super absorbent tampons and was first described in the 1980s. This led to regulations on the absorbency of tampons.
Saxbee Consultants holds the number 1 position across major social media platforms when searched, including Google, Yahoo, Bing, Facebook, LinkedIn, SlideShare, Twitter, and India Mart. The document lists Saxbee Consultants as having the top result on each of these search and social media sites.
According to research studies, employee health risks are directly related to increased costs for companies, as healthy employees can contribute up to 12.5% more to a company. The document also lists various health and wellness magazines and journals the trainer has experience with, and states that the goal is to help individuals tap their highest potential through healthier lifestyle choices involving exercise and mental stimulation.
Nurses and attendants are available to provide care for a healthy recovery. This email is regarding nurse staffing and bookings can be made by contacting nursingnursing@yahoo.in. Happy Nurse Day.
Saxbee Consultants is collecting ideas from the public to present to the Prime Minister of India on January 31, 2016. The public is encouraged to submit their ideas for building a stronger India by emailing them to saxbeeconsultantspm@gmail.com. Saxbee Consultants previously faced a technical issue that prevented emails from being received but their technicians have now fixed the problem, so the public is asked to resend any ideas they had submitted.
Saxbee Consultants is collecting ideas from the public to present to the Prime Minister of India on January 31, 2016. The public is encouraged to submit their ideas for building a stronger India by emailing them to saxbeeconsultantspm@gmail.com. Saxbee Consultants previously faced a technical issue that prevented emails from being received but their technicians have now fixed the problem, so the public is requested to resend any ideas.
Saxbee Consultants is collecting ideas from the public to present to the Prime Minister of India on January 31, 2016. The public is encouraged to submit their ideas for building a stronger India by emailing them to saxbeeconsultantspm@gmail.com. Saxbee Consultants previously faced a technical issue that prevented emails from being received but their technicians have now fixed the problem, so the public is asked to resend any ideas they had submitted.
Air India has introduced yoga sessions for newly-recruited cabin crew and pilots undergoing training, as well as a two-day yoga workshop for senior management, to help staff cope with stress and bring discipline. Trainees are required to attend early morning yoga sessions, while the workshop for managers will be held later in June. The initiatives were proposed by Air India's personnel department and coincide with Prime Minister Modi's push to celebrate International Yoga Day.
The author discusses the health risks of raising children in Delhi, India due to the city's extremely high air pollution levels. He describes how his young son was hospitalized twice for respiratory issues caused by Delhi's air. Experts advise that the pollution will likely cause permanent lung damage in children and reduce their life expectancy. While some expats choose to remain in Delhi for work, the author is reconsidering staying due to the threats to his family's health from the polluted air and contaminated water.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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. 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. 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. 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. 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. What’s Responsible for the Quality Chasm?
• A system oriented
to acute disease
that isn’t working
for patients or
professionals
7. What kind of changes to practice
systems improve care?
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. Shojania, K. G. et al. JAMA 2006;296:427-440.
The Effectiveness of QI Strategies: Findings from a Recent
Review of Diabetes Care
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
12. What distinguishes good chronic
illness care from usual care?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
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. 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.
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. Delivery System Design
Goal
To organize practice staff, schedules and
other systems to assure that all patients
receive planned, evidence-based care.
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. 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. Health Care Organization
Goal
To assure that practices within the
organization have the motivation, support
and resources needed to redesign their
care systems.
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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?
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
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..
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. 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
48. 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
49.
50. 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
51. 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
52. 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
53. 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
54. Ecological Model of Health Behavior
Community, Environment, Policy
Systems, Organizations, Businesses
Family, Friends
Peer Groups
Individual
63. 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
65. 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.
66. 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
67. 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
69. 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!
70. 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
71. 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
72. 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.
73. 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
75. 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.
76. 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
77. 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
78. 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
79. 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
80. Effective educational methods
Interactive, sequential opportunities in
small groups or individual training
• Academic detailing
• Problem-based learning
• Modeling (joint visits)
81. 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
86. This platform has been started by
Parveen Kumar Chadha with the
vision that nobody should suffer
the way he has suffered because
of lack and improper healthcare
facilities in India. We need lots of
funds manpower etc. to make this
vision a reality please contact us.
Join us as a member for a noble
cause.
The magnitude of the problem:
45% of the U.S. population suffers from one or more chronic illnesses, and over 60 million (21% of the population) have multiple conditions.
Anderson G, Horvath J. The Growing Burden of Chronic Disease in America, Public Health Reports, May–June 2004. Accessed February 6, 2007, at: http://www.publichealthreports.org/userfiles/119_3/119263.pdf
The Shojania article, also included in the earlier summary slide, illustrates the variety of QI strategies attempted and their effectiveness.
Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G.Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care. 2001 Aug;24(8):1365-70.
Evidence that just guideline didn’t change process or outcome in asthma and angina:
Eccles et al BMJ 2002;325:941 computerized guidelines, RCT in UK
Our premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78.
The essential element of good chronic illness care is a productive interaction, versus current interactions that tend to be frustrating for both patients and providers. An interaction can be a face-to-face visit, a phone call or an email message. Productive means that the work of evidence-based chronic disease care gets done in a systematic way, and patient needs are met.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66
The overarching definition of a productive interaction is one that assures that patient needs for evidence-based clinical and behavioral care information and support to become better self-managers, and monitoring over time are met.
To maximally improve outcomes, we need a different kind of patient. “Informed” means the patient has sufficient information to become a wise decision-maker related to their illness. Patients also need to be “activated” by understanding the importance of their role in managing the illness.
Let’s look at each of the elements in a little more detail:
Self-Management support: Empower and prepare patients to manage their health and health care.
Emphasize the patient’s central role in managing their health. Providers reinforce the patient's active and central role in managing their illness.
Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up. Evidence now strongly suggests that to achieve optimal outcomes in most chronic illness, we must improve the patients ability and interest in managing their own condition. The best tested strategy to support self-management employs the 5A’s.
Assessment includes not only knowledge but beliefs and behavior. (Knowledge isn’t enough to change behavior. We need to understand more about what patients value and what they do.)
Advice needs to be linked to scientific evidence, not provider biases.
Agree on goals that are important to patients and actions to reach them.
Assist by identifying barriers and problem-solving to deal with them.
Arrange a specific follow-up plan including utilizing internal and community resources to provide ongoing self-management support to patients.
One example of an effective program based in the community is the Chronic-Disease Self-Management Program developed by Stanford. It is a six-week scripted curriculum delivered by lay people with chronic illness.
Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care, 1999; 37(1):5-14.
Community: Mobilize community resources to meet needs of patients.
There are many important resources and services for patients that are not part of most medical systems: peer support groups, exercise programs, nurse educators, or dieticians often aren’t in small practices.
Encourage patients to participate in effective community programs. This means you need to first know what and where they are.
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services. For example, in the Seattle area, the University of Washington partnered with Group Health Cooperative and Senior Services to make “Lifetime Fitness” exercise program available in senior centers and community meeting rooms throughout the area. http://www.seniorservices.org
Advocate for policies to improve patient care such as insurance coverage for diabetes supplies.
Another potential way is to have health plans work together. In several states, health plans have coordinated chronic illness guidelines, measures, and care resources throughout the community.
The other side of the productive interaction is a practice team that is organized, trained, and equipped to conduct productive interactions.
Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support.
Delivery system design is where we all work everyday--(WHO is there and WHAT do they do to contribute to good quality care. This is about HOW we interact with patients.)
Most successful chronic care interventions involve increased clinical involvement of the non-physician members of the care team. We are talking about actually having a team who discusses the work they do, how they are going to do it, and how to improve on it. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998; 11(2):116-26.
Planned interactions have an agenda, like a routine physical or a prenatal visit. Planned visits can be either 1:1 or in groups. We can use a registry and tools to help set the agenda and not leave out critical parts of the care. McCulloch et al. Effective Clinical Practice 1998; 1:12-22 and Disease Management 2000; 3(2):75-82
Patients with complex needs, or engaged in an acute transition or exacerbation, often benefit from more intensive attention. The use of a clinical case or care manager, usually a nurse or a pharmacist, has been shown to be effective in diabetes, CHF, depression, and other illnesses.
Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In real estate, they say, Location, Location, Location. In chronic illness, it is Follow-up, Follow-up, Follow-up. Support for telephone follow-up: Nurses increase exercise in elderly primary care pts using phone calls: Journal of Geront: Medical Sciences 2002 vol 57A no 11 M733-M740.
Piette et al. Impact of automated phone calls and nurse calls on diabetes in the VA, Diabetes Care 2001; 24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction)
Patients should be routinely asked to “teach back” to check comprehension and if they are comfortable with the plan. Providers need to check in with patients to make sure that the interaction style is compatible with their cultural norms, values, and beliefs.
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
Decision support begins, but cannot end, with the dissemination of evidence-based guidelines. Distribution of guidelines alone has minimal impact. What does work is the integration of guidelines into the flow of clinical decision making.
We need to not only possess guidelines, but we must get them off the shelf or the computer screen and use them in decision making.
Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317
Our typical way of interacting with specialists is to refer a patient and hope to get a letter back. Some examples include shared care, real-time consultation, and email exchanges
Quinn et al. Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes. Jt Comm J Qual Improv 2001; 27:255
Katon et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5; 273(13):1026-31
McCulloch DK, Price M, Hindmarsh M, Wagner E. Improvement in Diabetes Care Using an Integrated Population-based approach in a Primary Care Setting. Disease Management 2000; 3(2):75-82.
Providers and care teams benefit from problem or case-based learning, academic detailing or modeling by expert providers.
Another thing we can do is to inform patients of guidelines pertinent to their care so they understand why a particular test, procedure, or screening is being performed.
Clinical information system: Organize patient and population data to facilitate efficient and effective care.
The crucial factor in improving chronic illness care is a clinical database that has the critical information that one needs to have a productive interaction (a registry). Even in the absence of a full electronic medical record (EMR), many registries can perform all the functions shown on the slide. Conversely, some EMRs may not be able to perform these functions so practices should be careful what information systems they employ to manage their patients’ care.
Health care organization: Create a culture, organization, and mechanisms that promote safe, high-quality care.
Visible support for leaders is believed to be critical for ongoing success.
Ovretveit et al. Quality collaboratives: lessons from research. Qual Saf Health Care 2002; 11:345-351.
Some QI strategies work. Langley and colleagues have categorized what they learned from helping organizations institute improvements.
References on Effective QI: Walshe & Freeman Qual Saf Health Care 2002 Mar; 11(1):85-87. Langley et al: The Improvement Guide, Jossey Bass, 1996
Encourage open and systematic handling of errors and quality problems to improve care. Safety has been a rallying cry for inpatient care and is becoming a concern in outpatient care. The system needs to be open and honest about handling errors in care and shortcomings in quality.
Reward care teams for quality of care, not just productivity. Not just physicians and not always monetary but through recognition, attending CME.
Develop agreements that facilitate care coordination within and across organizations. Work with local hospitals, VNS, and social service agencies in an open and coordinated manner. IOM Quality Chasm
The following slides discuss each of these types of evidence in turn.
STUDY SPECIFICS
A review of systematic reviews demonstrates that integrated care programs generally have positive outcomes. The most commonly used components of integrated care programs include: self-management support, patient education, case management, multidisciplinary patient care team, and clinical feedback/reminders/education. Authors caution that inconsistent definitions of interventions and outcomes are prevalent throughout the literature and, if ignored, can lead to inappropriate conclusions about the effectiveness of programs in meta-analyses.1
One of two reviews of depression treatment in primary care finds that complex interventions using clinician education, enhanced nurse case management, and greater integration between primary and specialty care are effective in improving patient outcomes. Less complex interventions like provider education alone are less likely to be effective.2
Badamgarav and colleagues conducted systematic evaluation of disease management. Lack of a clear definition of “disease management” makes interpreting the findings difficult, but in general they found an improvement in patient satisfaction, adequacy of prescribed treatment, and other quality of care markers. They also found increases in costs associated with hospitalization and treatment costs among the intervention groups as compared to controls.3
A review of quality improvement strategies in hypertension finds that interventions that include team care are associated with the greatest improvement in blood pressure outcomes. Here, team care is defined as the “assignment of some responsibilities to a health professional other than the patient's physician.” Other strategies that proved effective include patient education and self-management support.4
Glasgow and colleagues published a literature review and expert recommendations for future research around diabetes care as part of the Health Care Delivery Work Group. They find that the continued focus on acute illness, rather than proactive chronic care management, is the cause for poor-quality diabetes care processes and outcomes. They cite articles showing that self-management support, improved patient-provider communication, and collaborative goal setting are linked to improved behavioral, biological, and quality of life outcomes. They also cite that a population focus, inclusion of clinician prompts and reminders, and a quality clinical information systems that supports disease registries are helpful tools to improve care.5
A second systematic review of diabetes shows that multifaceted interventions that “facilitate structured and regular review of patients were effective in improving the process of care.” Renders et al finds that studies rarely assess outcomes. Like the studies above, they find that clinician education with performance feedback and use of care teams seemed to improve care.6
A recent Cochrane review of diabetes care finds that in 58 papers with 66 comparisons, quality improvement initiatives that used team changes and those that use case management with the ability to influence physicians’ prescribing patterns showed the largest difference in post intervention HbA1c scores.7
Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005; 17(2):141-6.
Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003; 289(23):3145-51.
Badamgarav E, Weingarten SR, Henning JM et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003; 160(12):2080-90.
Walsh JM, McDonald KM, Shojania KG et al. Quality improvement strategies for hypertension management: a systematic review. Med Care 2006; 44(7):646-57.
Glasgow RE, Hiss RG, Anderson RM et al. Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care 2001; 24(1):124-30.
Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care 2001; 24(10):1821-33.
Shojania KG, Ranji SR, McDonald KM et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006; 296(4):427-40.
STUDY SPECIFICS
There is a significant relationship between a practice’s primary care orientation and its implementation of the CCM. Specifically, medical groups (as opposed to IPAs) that accept risk for hospitalization costs, use health promotion programs, have an electronic standardized problem list, and are required to report patient process and outcome measures appear to use more chronic care management practices.1
Flemming et al. studied 134 managed Medicare organizations and collected diabetes quality measures (HbA1c, LDL, microalbuminuria and eye exams). They assessed 32 care elements based on the CCM and compared top and bottom quartiles on quality (e.g., HbA1c > 9.5–20% vs. 50%). Top quartile more likely to employ CCM elements, especially: computerized reminders, practitioner involvement on QI teams, guidelines supported by academic detailing, formal self-management programs, a registry.2
Staff participation in practice decisions and optimization of the clinical care team to include non-physician staff can improve the delivery of preventive services. In addition, improved clinical systems such as reminders and patient registries are associated with improved delivery of preventive services.3
Overall, physician organizations have not adopted as many components of the diabetes care management index as we would expect. 47% use one or fewer care management processes. A number of factors were associated with increased use of care management processes: Reporting data to external organizations; receiving income, recognition, or better contracts for quality; improved IT infrastructure; ownership by HMO or hospital system; receiving capitated payments; and large size.4
1. Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV. Effect of primary health care orientation on chronic care management. Ann Fam Med 2006; 4(2):117-23.
2. Fleming B, Silver A, Ocepek-Welikson K, Keller D. The relationship between organizational systems and clinical quality in diabetes care. Am J Manag Care 2004; 10(12):934-44.3. Hung DY, Rundall TG, Crabtree BF, Tallia AF, Cohen DJ, Halpin HA. Influence of primary care practice and provider attributes on preventive service delivery. Am J Prev Med 2006; 30(5):413-22.
4. Li R, Simon J, Bodenheimer T et al. Organizational factors affecting the adoption of diabetes care management processes in physician organizations. Diabetes Care 2004; 27(10):2312-6.
RAND Evaluation of the Improving Chronic Illness Care was a multimillion dollar evaluation effort sponsored by the Robert Wood Johnson Foundation. Because of the size and robustness of that evaluation, those findings are highlighted separately in the next few slides.
See www.rand.org/health/projects/icice/ for details.
STUDY SPECIFICS
Over four-fifths of the organizations implemented some interventions in all six CCM elements. However, there were differences: since many elements of the CCM depend on having a registry of patient, sites worked most intensely on improving information support (24% of all their efforts, on average) and least intensely on developing community linkages (8% of their efforts).1
Pearson ML, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res. 2005 Aug; 40(4):978-96.
STUDY SPECIFICS
The 10-year risk of cardiovascular disease was determined using a modification of the U.K. Prospective Diabetes Study risk engine. The baseline 10-year risk was 31% for both cases and controls. At the end of the period, the intervention group had a 2.1% greater reduction in predicted risk.1
Participation in the collaborative for Heart Failure was associated with fewer emergency department visits.2 The RAND team also utilized medical record review to measure performance on 23 predefined quality indicators for sites participating in the heart failure collaborative. Patients from collaborative sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P _ 0.0001). The improvement was greatest for measures of education and counseling (24% versus _1%, P _ 0.0001).3
The overall process of pediatric asthma care improved significantly in the intervention group but remained unchanged in the control group (change in process score +13% vs 0%; P < .0001). Patients in the intervention group were more likely than patients in the control group to monitor their peak flows (70% vs 43%; P < .0001) and to have a written action plan (41% vs 22%; P = .001). Patients in the intervention group had better general health-related quality of life (scale score 80 vs 77; P = .05) and asthma-specific quality of life related to treatment problems (scale score 89 vs 85; P < .05).4
The RAND study of adult asthma care had a smaller study population and found process of asthma care improved significantly, as did patient satisfaction with communication, but outcomes were not significantly different from controls.5
1. Vargas R, et al. Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes? JGIM, Pre-published online at: http://www.springerlink.com/content/x18u42332535t426/fulltext.html. Accessed January 29, 2007
Baker DW, Asch SM, Keesey JW, Brown JA, Chan KS, Joyce G, Keeler EB. Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation. J Card Fail. 2005 Aug; 11(6):405-13. PMID: 16105630 .
Asch SM, Baker DW, Keesey JW, Broder M, Schonlau M, Rosen M, Wallace PL, Keeler EB. Does the collaborative model improve care for chronic heart failure? Med Care. 2005 Jul; 43(7):667-75.
Mangione-Smith R, et al. Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care? Ambul Pediatr. 2005 Mar-Apr; 5(2):75-82.
Schonlau M, et al. Evaluation of a quality improvement collaborative in asthma care: does it improve processes and outcomes of care? Ann Fam Med. 2005 May-Jun; 3(3):200-8.
STUDY SPECIFICS
Used disease registry, diabetes nurse case managers, and group visits to improve diabetes outcomes in rural, minority populations in Eastern North Carolina. Pre-post findings indicated an increase in patients with self-management goals who received lipid panel, used aspirin and received a foot exam.1
Pre-post examination of Midwestern CHCs’ participation in the Diabetes Health Disparities Collaborative showed increased process measures, like rates of HbA1c measurement, eye examination referral, foot examination and lipid assessment. Mean value of HbA1c also decreased. Survey respondents felt the effort was worth it and successful. Practices struggled in: needing more time, developing a patient registry, staff turnover, more support by senior management.2
Teams implementing CCM as part of the Diabetes BTS collaborative improved their self-management support capabilities, as measured both by self report and objective data. Among heart failure collaboratives, daily self-monitoring of weight by patients improved significantly (19% to 93%) and teams provided education significantly more often to patients.3
Harwell and colleagues supported primary care practices with performance feedback. Practices then did a variety of additional system changes. This cross-sectional study found improvements in some processes – foot examinations, microalbumin testing, dilated retinal examination – but not others like HbA1c testing or LDL-C testing.4
Multiple North Carolina residency practices participated in the BTS collaboratives and implemented strategies across all elements of the CCM. Practices evaluated themselves at base-line and after using the ACIC. Study found that key measures of diabetes care were improved in two-thirds of practices.5
Practices in Wisconsin and Minnesota that implemented planned care and DEMS found that planned care plus use of a disease registry improved care across all 12 performance measures. Planned care alone or in conjunction with DEMS improved metabolic outcomes. DEMS alone improved process measures, but not metabolic outcomes.6
Implementation of the CCM in a rural Pennsylvania practice resulted in significant improvement in adherence to ADA guidelines including 2 HbA1c tests per year, lipid profile, urinalysis, eye exam, and foot exam performed. Mean HbA1c also declined significantly, as did mean HDLc levels. Improvement in three empowerment measures was seen, though it wasn’t significant.7
Among a highly transient, uninsured population, significant improvements in diabetes outcomes including decreased LDL, HbA1c, and Arterial Pressure were observed. 8
Case studies from North Carolina show that participation in the CCM collaborative resulted in improved HbA1c values for diabetics. Factors contributing to success included senior leadership support, physician champions, and multidisciplinary teams. Staff turnover was a barrier.9
A Washington state initiative to conduct state-level collaboratives around diabetes care resulted in some improvement in process and outcome measures in most of the 47 participating teams. Absolute improvement was higher for process measures than for outcome measures. 10
One study used the CCM framework to improve the delivery of diabetes self-management training. They found the framework useful in terms of improving the number of DSMT programs offered, enhancing reimbursement to cover costs, and lowering patients HbA1c –ostensibly by offering more patients self-management support. 11
The implementation of the Chronic Care Model produced different results when used at two different primary care practices in London. One site showed significant improvements in identification and case management of depression; the other did not. Tangible barriers like a primative information technology system, lack of experience with chronic disease management, and the inability to find common meeting time proved serious barriers to the implementation of the project in the second site. Other, intangible barriers which mediated the impact of the CCM at the second site included a lack of staff ownership, participation, and buy-in as well as lack of external support for the elements of the project. 12
Sites participating in the Breakthrough Series Collaborative for HIV/AIDS did not show improvement on process or outcome measures when compared to other clinics that did not participate in the BTS collaborative. The proportion of patients with a suppressed viral load decreased in the intervention group, compared to the control group, but the decrease was not significant. 13
Bray P, Roupe M, Young S, Harrell J, Cummings DM, Whetstone LM. Feasibility and effectiveness of system redesign for diabetes care management in rural areas: the eastern North Carolina experience. Diabetes Educ 2005; 31(5):712-8.
Chin MH, Cook S, Drum ML et al. Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative. Diabetes Care 2004; 27(1):2-8.
Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002; 24(2):80-7.
Harwell TS, McDowall JM, Gohdes D, Helgerson SD. Measuring and improving preventive care for patients with diabetes in primary health centers. Am J Med Qual 2002; 17(5):179-84.
Landis SE, Schwarz M, Curran DR. North Carolina family medicine residency programs' diabetes learning collaborative. Fam Med 2006; 38(3):190-5.
Montori VM, Dinneen SF, Gorman CA et al. The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care 2002; 25(11):1952-7.
Siminerio LM, Piatt G, Zgibor JC. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes Educ 2005; 31(2):225-34.
Stroebel RJ, Gloor B, Freytag S et al. Adapting the chronic care model to treat chronic illness at a free medical clinic. J Health Care Poor Underserved 2005; 16(2):286-96.
Wang A, Wolf M, Carlyle R, Wilkerson J, Porterfield D, Reaves J. The North Carolina experience with the diabetes health disparities collaboratives. Jt Comm J Qual Saf 2004; 30(7):396-404.
Daniel DM, Norman J, Davis C et al. A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State. Jt Comm J Qual Saf 2004; 30(2):69-79.
Siminerio LM, Piatt GA, Emerson S et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ 2006; 32(2):253-60.
Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002; 325(7370):951-4.
Landon BE, Wilson IB, McInnes K et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med 2004; 140(11):887-96.
These trials all tested multi-component interventions based on the CCM in primary care.
STUDY SPECIFICS
Sustained reductions in HbA1c of 1% or more result in cost savings within one to two years of improvement. Cost savings are highest for individuals with highest HbA1c levels at baseline. Utilization of primary care and specialty care were significantly lower among the “improved’ group, but hospitalization rates were not affected.1
Reviewing 44 articles examining the ROI of DM programs showed that some evidence suggests a positive ROI for CHF and multiple disease conditions. Results were mixed for asthma, diabetes, and depression studies, and depended on what types of costs were included (e.g. productivity).2
Gilmer and O’Connor propose that the elements of disease management that are cost effective include: disease management programs, clinical management, and self-management training. Evidence is still needed to support both the costs and effectiveness of these recommendations.3
Organizational features and improvement strategies differentially affect future health care costs. For example, interventions focusing on the increased use of pharmaceuticals to improve care are associated with increased health care costs. Interventions that focus on clinical meetings, registries, and resource use related to diabetes or heart disease care are associated with lower costs.4
Wagner EH, Sandhu N, Newton KM, McCulloch DK, Ramsey SD, Grothaus LC . Effect of improved glycemic control on health care costs and utilization. JAMA 2001; 285(2):182-9.
Goetzel RZ, Ozminkowski RJ, Villagra VG, Duffy J. Return on Investment in Disease Management: a Review. Health Care Financ Rev 2005; 26(4):1-19.
Gilmer T, O’Connor PJ. Cost Effectiveness of Diabetes Mellitus Management Programs - a Health Plan Perspective. Disease Management & Health Outcomes 2003; 11(7):439-53.
Gilmer TP, O'Connor PJ, Rush WA et al. Impact of office systems and improvement strategies on costs of care for adults with diabetes. Diabetes Care 2006; 29(6):1242-8.
Since most of the day to day management takes place in the lives of patients and the communities where they live and work, it’s appropriate to first look at the two left most elements of the model where patients spend their time. How do we start where patients are and carry the benefits of optimal medical care out into the community so that patients and families can do the best possible job of managing their chronic conditions?
Let’s examine a perspective that influence the way we interact with patients about their condition. How many of you would agree with this statement? This little change of focus might get us focused in a more productive way, on the roles both patients and clinical teams play in controlling chronic conditions.
Many of the changes that that patients and families need to make to manage their conditions are ones that require continuous effort over long periods of time. It helps to have support from friends, family, your doctor and nurse. This must be a great group, because I can’t remember the last time I was laughing when I stepped on a scale. Let’s look at the changes required for good care for chronic conditions.
This chart was developed by Kate Lorig at Stanford University to help people with chronic conditions understand the difference between acute and chronic conditions. If we have pneumonia or a skiing accident, we have a pretty good chance of being diagnosed and treated rapidly and effectively, but without regular preventive care, a person with diabetes may have no symptoms for years, even though their body is becoming less and less able to use carbohydrates efficiently, and high glucose levels in the blood are doing damage to kidneys and eyes. These are some pretty big differences, but they have some even bigger implications.
The more important point of the comparison between short term and long term diseases is to recognize that the longer timeframe of chronic conditions changes the kind of relationship needed between care providers and patients. With the pneumonia, we expect to be inconvenienced by therapy, and even if it is very inconvenient – bed rest for a week, it won’t last too long and we can put up with it because we expect a cure. We’ll put aside our own preferences, even our own judgment, listen to the doc and do what she says. But when the length of the illness is indefinite and the condition makes normal functioning difficult or impossible, most of the “treatment” is really day to day management, and happens outside the healthcare system - at home. The patient is in charge here. Kate says, “Everybody self-manages. The question is how well they self-manage.” So good self-management benefits from a different kind of relationship between patients and health care professionals. Clinicians offer medical advice much like a teacher or coach. People with chronic conditions and our families carry out the treatments at home through our behaviors. We monitor symptoms and how well the treatment is working, and make decisions about managing treatment in our own environment. The doc is the medical expert, we are the expert on managing day to day. We need help recognizing this difference in order to understand that we need to take a more active role in managing our conditions. Now let’s look at another concept to help set the stage for better self-management.
What is more, we may begin to think that everything is due to the disease, and forget that other factors play a part, unaware that other factors can make symptoms of chronic illness seem worse. We may blame our disease for feeling tired or anxious or tense, and then these problems interact with each other, making everything seem worse. If we understand these other factors, we can learn skills and techniques that help us deal with each of them, even though our chronic disease cannot be cured. The symptom cycle shows these other factors, and the program teaches skills that address them, giving people more control over the effects of their illness and greater chance of leading the lives they choose.
“Why wouldn’t a person with diabetes do everything in their power to live long and feel well?” Maybe it has something to do with the finer points of how we interact with them.
Although persuasion has some role, it may have some drawbacks.
Hagar and many patients probably feel similarly about persuasion.
Although we call it follow up, this graphic helps us understand that supporting patients in managing their illness is an ongoing cyclical process. Teams start by thinking about visit preparation, what happens in the visit and follow up after the visit, but with practice it all becomes part of the ongoing cycle of care, the continuous healing relationship described in the Quality Chasm report.
Here are the change concepts for community resources. Our changes will be made based on these ideas.
Family friends and peers
Group medical visits
Community health worker services
Peer-led self management courses
Groups
Peer and professional-led support groups
A trained peer who applies his or her unique understanding of the experience, language and culture of the populations he or she serves to promote healthy living and to help people take greater control over their health and their lives. CHWs are trained to work in a variety of community settings, partnering in the delivery of health and human services to carry out one or more of the following roles:
Providing culturally appropriate health education and information
Linking people to the services they need
Providing direct services, including informal counseling and social support
Advocating for individual and community needs, including actively building individual and community capacity.
Community health workers also known as promotoras, offer culturally appropriate health coaching and provide a valuable link between people from varied cultural and ethnic groups and their healthcare system. They can become the eyes and ears of the clinician in the community.
Community health workers can take health information and support out to people where they live and work.
Second “level of influence”—organizations
Leveraging changes within organizations
Tasty Fork
Lay health educators at worksites
Healthy breakroom
Walking patient visits
Linkages with organizations/ departments
Referrals to community exercise center with incentives for continued participation
Sharing intake data across health and social services to aid referrals and seamless care
Shared positions
Participatory program planning through a Diabetes
Community Council
· Use of a Circle Model of community organizing for
designing diabetes self management activities
· Case management for enrollees of the Full Circle
Diabetes Program
· Living in Balance chronic disease self management
workshops led by trained members of the Diabetes
Community Council
More complex partnerships take more resources
1—put you in my brochure (BCI)
2—reciprocal referrals—(Campesinos)
3—plan together so service complement—ODHC
4—full integration--MAIC
Third “level of influence”—environment and policy
Advocacy for food choices in grocery stores
Placing educational materials in libraries
Participation in community events, coalitions and partnerships
Advocacy for walkable towns - Latin America’s Bicycle Sundays, 100,000 families
Open with reminding audience of where they are in the Chronic Care Model. Mention that information systems are the glue that holds all of the system redesign work together because without it you can never be sure who your patients are, what care they are receiving and how the changes you make in other areas of the model are actually impacting outcomes.
Clinical information system: Organize patient and population data to facilitate efficient and effective care.
The crucial factor in improving chronic illness care is a clinical database that has the critical information that one needs to have a productive interaction (a registry). Even in the absence of a full electronic medical record (EMR), many registries can perform all the functions shown on the slide. Conversely, some EMRs may not be able to perform these functions so practices should be careful what information systems they employ to manage their patients’ care.
Convince nay-sayers with practical demonstrations of how CIS facilitates improved care.
Competing demands need to be addressed by senior leaders so that CIS work receives equal billing.
Teams need to understand how their daily flow works so that fitting the registry into the process is seamless versus an add-on.
Again, senior leaders need to free up IT support to facilitate CIS use and spread
A computer model was created to project the impact of IT-enabled disease maangement on care processes, outcomes and medical costs for patients with type 2 diabetes. Several technologies were modeled (registries, comp. decisions support, remote monitoring)
Nationally, diabetes registries over 10 years saved $14.5 billion, ($1,016 per enrolled patient)
computerized decision support saved $10.7 billion
Integrated provider-patient systems save $16.9 billion
Two-thirds of the public (65%) is interested in accessing their own personal health
information electronically. This interest spans demographic groups – with a
majority (53%) of Americans 60 and older and high proportions of minority groups,
including African-Americans and Latinos, expressing interest.
Large majorities see a number of benefits of accessing information online, which
could lead to a reduction in health care costs. For example, nearly nine in 10
Americans (88%) say online records would be important in reducing the number of
unnecessary or repeated tests and procedures they undergo.
Americans express strong concern that their information may be used for purposes
other than their own care. Eight in 10 Americans (80%) say they are very
concerned about identity theft or fraud or the possibility of their information getting
into the hands of marketers (77%).
Americans believe they could gain more control over their health care by using
electronic personal health records. For example, ninety percent say it would be
personally important to track their symptoms or changes in health care online.
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
Decision support begins, but cannot end, with the dissemination of evidence-based guidelines. Distribution of guidelines alone has minimal impact. What does work is the integration of guidelines into the flow of clinical decision making.
We need to not only possess guidelines, but we must get them off the shelf or the computer screen and use them in decision making.
Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317
Our typical way of interacting with specialists is to refer a patient and hope to get a letter back. Some examples include shared care, real-time consultation, and email exchanges
Quinn et al. Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes. Jt Comm J Qual Improv 2001; 27:255
Katon et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5; 273(13):1026-31
McCulloch DK, Price M, Hindmarsh M, Wagner E. Improvement in Diabetes Care Using an Integrated Population-based approach in a Primary Care Setting. Disease Management 2000; 3(2):75-82.
Providers and care teams benefit from problem or case-based learning, academic detailing or modeling by expert providers.
Another thing we can do is to inform patients of guidelines pertinent to their care so they understand why a particular test, procedure, or screening is being performed.
Note that evidence is modified by patient circumstances and preferences. Guidelines were never meant to dictate the care that is provided, but to inform it and eliminate variation that is detrimental to patient outcome.
Collins et al. From theory to practice: Identifying authentic opinion leaders to improve care. Managed Care July 2000 p 56-62
Berg et al. Clinical practice guidelines in practice and education. J Gen Inter Med 1997;12(S2):S25-S33.
Stepped care is the main way chronic conditions are treated successfully, including behavioral interventions.
Shared care agreements are used to delineate which provider will do which aspect of care. For example, post MI, the cardiologist may see the patient very soon after discharge to review medications or perform tests, then the primary care physician may provide expertise on lifestyle intervention.
Alternating visits has been used for some patients with depression or asthma.
Joint visits are one of the main ways Group Health Cooperative keeps primary care providers current on diabetes treatment. The specialist and PCP see the patient together. The specialist is part of a roving expert team with a diabetes nurse expert who mentors office nurses. McCulloch et al Eff. Clin Prac 1998;1:12,
Dis Mgmt 200;3:75)
On-call specialists are instructed to respond to pages from primary care even if they are with the CEO. Their on-call time is compensated and valuable to the organization.
Nurse case-managers who are linked with specialists can bring expertise into primary care. (Aubert et al Ann Int Med 1998;129:605)
Academic detailing is borrowing a page from the pharmaceutical reps, but having the content not be a new drug to prescribe, but new evidence-based clinical information.
Problem-based learning is frequently case studies or walking through a case, much as providers are trained.
Modeling allows clinicians to observe another in practice and try the techniques for themselves.
Whitlock et al http://www.ahrq.gov/clinic/3rduspstf/behavior/behsum1.htm
Result: better diagnosis, continuing care and guideline based care in children with asthma
Evans et al, Pediatrics 1997;99:157
There is less of an evidence-base for providing patients with guidelines and the impact that has on care, but there is some evidence that patients who are prepared for a visit receive better care.
Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Int Med. 1995;10:59-66.