Transcript The Patient's Role In Chronic Illness Care

The Chronic Care Model
Presenter
Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation
Living with chronic illness is like
piloting a small plane
To get safely to their destination
pilots need:
• Flight instruction
• Self-Management
Support
• Preventive
Maintenance
• Effective Clinical
Management
• Safe Flight Plan
• Treatment Plan
• Air Traffic Control
Surveillance
• Close Follow-up
Usual care works well if your
plane is about to crash
Three Biggest Worries About Having A
Chronic Illness (Age 50 +)
1. Losing Independence
2. Being a Burden to Family or
Friends
3. Not Being Able to Afford Needed
Medical Care
Percent Somewhat or Strongly
Disagreeing With Statements
Age 50-64
Age 65+
Government programs are
adequate to meet the needs
of people with chronic
medical conditions
65%
47%
Health insurance pays for
most of services chronically
ill people need
55%
43%
People with chronic medical
conditions receive adequate
medical care
66%
52%
Number of Chronic Conditions per
Medicare Beneficiary
Number of
Conditions
Percent of
Beneficiaries
Percent of
Expenditures
0
18
1
1
19
4
2
21
11
3
18
18
4
12
21
5
7
6
3
13
7+
2
14
63%
18
95%
Prevalence of chronic conditions
• 10.3 % have heart disease
• 23% have HTN
• 9.1% have asthma
• 6.2% have diabetes
• Prevalence of HTN and diabetes
increased in Hispanics and blacks
The IOM Quality report: A New Health
System for the 21st Century
http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument
The IOM Quality Report:
Selected Quotes
• “The current care systems cannot do
the job.”
• “Trying harder will not work.”
• “Changing care systems will.”
IOM Report: Six Aims for Improving
Health Systems
• Safe - avoids injuries
• Effective - relies on scientific knowledge
• Patient-centered - responsive to patient
needs, values and preferences
• Timely - avoids delays
• Efficient - avoids waste
• Equitable - quality unrelated to
personal characteristics
Recent literature on care
• Insert here
• Recently published literature that
demonstrates the gap between what we
know and what we do.
•
Diabetes
• 69% had HbA1c test in last year
• 63% had feet checked
• 64% had dilated eye exam
• Among uninsured, only 62% had HbA1c,
48 % a foot exam, 49% an eye exam)
Asthma
• 48% take prescribed medications
• 29% report using steroid inhalers
• 17% report having a peak flow meter at
home
Use of statins in pts with MI
• 60% of patients over age 65 with a history
of a heart attack were on a cholesterollowering medication
• 33% knew the result of their most recent
cholesterol measurement
Ayanian et al Arch Inter Med 2002;162:1013
Hypertension care in US
• Over 16,000 patients
• 27% had hypertension
• 15-24% had controlled hypertension
• 27-41% unaware that they had hypertension
• 25-32% had treated uncontrolled hypertension
• 17-19% aware of hypertension but it was
untreated
NEJM 2001;345:479-486
Physician treatment practices for
hypertension
• 41% had not heard of JNC guidelines
• JNC guidelines recommend treatment to
140/90
• 43% of MDs would not start therapy
unless systolic >160 and 33% would not
start treatment unless diastolic >95
• Most would choose ACE for first drug
Hyman et al Arch Inter Med 2000;160:2281
Children with asthma
• Affects 75 children per 1,000
• Disproportionately affects children of low
income families, males and blacks over whites
• 24% of children with asthma miss two or more
weeks of school (8% of children without asthma
have the same attendance figures.)
• The healthcare expenditures for a child with
asthma are 2.5 times that of a child without
asthma.
Diabetes Care in the U.S.
Harris. Diab Care 2000;23:754-8
100%
80%
60%
40%
20%
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The Watchword
Systems are perfectly
designed to get the
results they achieve
Improving Chronic Illness Care
A national program of the Robert Wood Johnson
Foundation
 Mission
to improve the health of chronically ill patients
by helping health plans and provider groups,
especially those that serve low income
populations, improve their care of the
chronically ill.
A Recipe for Improving Outcomes
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Evidence-based
Clinical Change
Concepts
Act
Plan
Study
Do
System change strategy
Participants
System Change
Concepts
Select
Topic
Prework
Planning
Group
P
Identify
Change
Concepts
A
P
D
A
S
LS 1
P
D
A
S
LS 2
D
S
LS 3
Action Period Supports
(12 months time frame)
E-mail
Visits
Phone
Assessments
Web-site
Senior Leader Reports
Learning
Model
Event
System Change Concepts
Why a Chronic Care Model?
• Emphasis on physician, not system,
behavior
• Characteristics of successful
interventions weren’t being categorized
usefully
• Commonalities across chronic conditions
unappreciated.
Model Development 1993 -• Initial experience at GHC
• Literature review
• RWJF Chronic Illness Meeting -- Seattle
• Review and revision by advisory committee of 40
members (32 active participants)
• Interviews with 72 nominated “best practices”,
site visits to selected group
• Model applied with diabetes, depression, asthma,
CHF, CVD, arthritis, and geriatrics
Essential Element of Good Chronic
Illness Care
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
What characterizes a “prepared”
practice team?
Prepared
Practice
Team
At the time of the visit, they have the patient
information, decision support, people,
equipment, and time required to deliver
evidence-based clinical management and
self-management support
What characterizes a “informed,
activated” patient?
Informed,
Activated
Patient
Patient understands the disease process,
and realizes his/her role as the daily self manager.
Family and caregivers are engaged in the patient’s
self-management. The provider is viewed
as a guide on the side, not the sage on the stage!
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
•Assessment of self-management skills and
confidence as well as clinical status
•Tailoring of clinical management by stepped
protocol
•Collaborative goal-setting and problem-solving
resulting in a shared care plan
•Active, sustained follow-up
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Self-management Support
• Emphasize the patient's central role.
• Use effective self-management support
strategies that include assessment, goalsetting, action planning, problem-solving
and follow-up.
• Organize resources to provide support
Delivery System Design
• Define roles and distribute tasks amongst team
members.
• Use planned interactions to support evidencebased care.
• Provide clinical case management services.
• Ensure regular follow-up.
• Give care that patients understand and that fits
their culture
Features of case management
•
•
•
•
•
Regularly assess disease control, adherence,
and self-management status
Either adjust treatment or communicate need
to primary care immediately
Provide self-management support
Provide more intense follow-up
Provide navigation through the health care
process
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.
Clinical Information System
• Provide reminders for providers and patients.
• Identify relevant patient subpopulations for
proactive care.
• Facilitate individual patient care planning.
• Share information with providers and
patients.
• Monitor performance of team and system.
Health Care Organization
• Visibly support improvement at all levels, starting
with senior leaders.
• Promote effective improvement strategies aimed
at comprehensive system change.
• Encourage open and systematic handling of
problems.
• Provide incentives based on quality of care.
• Develop agreements for care coordination.
Community Resources and
Policies
• Encourage patients to participate in effective
programs.
• Form partnerships with community organizations
to support or develop programs.
• Advocate for policies to improve care.
To Change Outcomes (e.g., HbA1c) Requires
Fundamental Practice Change
• Interventions focused on
guidelines, feedback, and
role changes can improve
processes
• Interventions that address
more than one area have
more impact
• Interventions that are patientcentered change outcomes.
Renders et al, Diabetes Care, 2001;24:1821
Impact of disease management on
control (number of positive trials)
• Provider education =
12/32
• Patient education =
24/55
• Provider feedback =
9/23
• Patient reminders =
6/16
• Provider reminders =
6/14
• Patient financial
incentives =3/4
Weingarten et al BMJ 2002;325:925
Features of case management
•
•
•
•
•
Regularly assesses disease control,
adherence, and self-management status
Either adjusts treatment or communicates
need to primary care immediately
Provides self-management support
Provides more intense follow-up
Provides navigation through the health care
process
Impact of Planned Care and Collaborative
Goal-Setting
• Randomized Danish GPs to diabetes
intervention groups
• Intervention group trained to provide regular
goal-setting in periodic structured visits with
their diabetic patients
• Study team provided guidelines, training,
reminders, and regular feedback
• Mean HbA1c significantly better years later
Olivarius et al. BMJ 10/01
Planning Productive Interactions for Chronic
Conditions
For Example: Diabetic Needs
Additional Diagnoses*
45%
Functional Limits**
50%
> 2 Symptoms***
35%
Not Good Health Habits
30%
*Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung 17%)
** Physical (31%), pain (28%), emotional (16%), daily activities (16%)
*** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue(23%), foot
(21%), backache (20%)
Advantages of a General System Change
Model
• Applicable to most preventive and
chronic care issues
• Once system changes in place,
accommodating new guideline or
innovation much easier
• Early participants in our collaboratives
using it comprehensively
The Growing Burden of Non-communicable
Disease
• Rapidly aging population
• Increased environmental risks—smoking,
changed diet, increasing inactivity, air
pollution
• Double jeopardy: still fighting infectious
disease and malnutrition while
experiencing impacts of chronic disease
W.H.O. Innovative Care for Chronic Conditions, 2002
Conmmunity is Critical Source of Care and Support
Applying the CCM to prevention
Similarities:
• Require regular attention to behavior change
• Are population-based
• Require planned care and active follow-up
• Use decision guides and occur in primary care
• Require patient involvement
• Require provider training
• Community linkages are helpful
Applying the CCM to prevention
Differences:
• Prevention visits are less frequent
• Changing behaviors to prevent something may
be different than when have an illness
• Prevention may not be as well reimbursed
• Benefits of prevention more difficult to perceive
• Few people specialize in prevention
Glasgow et al Milbank Quarterly 2001;79:579
Contact us:
•www.improvingchroniccare.org
thanks
Congestive Heart Failure -- Rich et al
Community
SelfManagement
Support:
Standardized
educational
program
Informed,
Activated
Patient
Health System:
Barnes-Jewish Hospital St. Louis
Decision
Support:
Guidelines
Ongoing
consultation
with
cardiologist
Productive
Interactions
Delivery
System
Design:
Nurse case
manager
Hospital and
home visits
Telephone F/U
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Rich et al, NEJM 1995
Clinical
Information
Systems
Reduce readmission rate
Non-significantly lower mortality
Increased quality of life
Cooperative Health Care Clinic
Community
SelfManagement
Support:
Health System:
Kaiser-Permanente Colorado
Decision
Support:
Group
Provider
Education
Peer Interaction Education,
Clinical
Priorities
Informed,
Activated
Patient
Productive
Interactions
Clinical
Delivery
Information
System
Systems
Design:
Patient
Multidisciplinary
Notebook
Group Visits
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Beck et al, JAGS
1997;45:543
Decreased emergency room use, repeat admits, specialist use
Increased calls to nurses, decreased calls to doctors
Increased immunizations
Increased satisfaction for patient and provider
Health Enhancement Project
Health System:
GHC and PacifiCare
Community:
Northshore Senior
Center
SelfDecision
Management
Support:
Support:
EvidenceIndividual and
based
Group Interactions Protocols
Informed,
Activated
Patient
Productive
Interactions
Delivery
System
Design:
GNP visits,
peer mentors
Prepared,
Proactive
GNP reporting to
PCP
Functional and Clinical Outcomes:
Leveille et al, JAGS
1998;46:1191
Clinical
Information
Systems:
Electronic
Chart and
Follow-up
System
Decreased disability and increased activity levels
Decreased hospitalization
Increased socialization
Decreased psychoactive medication use
The Diabetes Clinical Improvement Roadmap
Health System:
Community
Group Health Cooperative of Puget Sound
SelfManagement
Support:
Decision
Support:
Guidelines,
Expert
Right Track
Team,
Notebook/Phone
Provider
Program,
Lorig Support Education
Groups
Informed,
Activated
Patient
McCulloch et al Eff.
Clin Prac 1998;1:12,
Dis Mgmt 200;3:75
Productive
Interactions
Delivery
Clinical
System
Information
Design:
Systems
Multidisciplinary On-line Registry,
Group Visits,
Practice
Planned visits,
Reports,
Retinal Screening Reminders,
Program
Patient
Summaries
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Increased retinal, foot and renal screening rates,
Increased Hemoglobin A1c testing,
Increased proactive/planned care,
Reduced costs,
Increased satisfaction for patient and provider
Ongoing Depression Treatment
Health System:
Community
12 PCPs in US metro and non-metro)
SelfManagement
Support:
Decision
Delivery
Support:
System
AHCPR
Design:
office nurse provided
PCP, nurse and guidelines
info on treatment
office staff all Psychiaoptions, readiness
trist review
involved.
intervention, tx
Monthly contact and advice
effectiveness
with pts by phone on tx
adjust
assessment
via nurse
Informed,
Activated
Patient
Productive
Interactions
Clinical
Information
Systems
Pt roster with tx
summaries,
feedback to care
team
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Rost et al BMJ
2002;325:934
Incr. Use of antidepressants
Incr. Use of counseling
80% remission in 2 yrs (40% for usual care)
Higher role functioning
Diabetes Nurse Case Management
Health System:
Community
Prudential Jacksonville
SelfManagement
Support:
1:1 visits with
trained RN,
follow-up
support,
pt. Ed class
Informed,
Activated
Patient
Decision
Support:
Detailed
management
algorithms
,
specialist
consult.
Productive
Interactions
Delivery
Clinical
System
Information
Design:
Systems
case mgmt.
diabetes registry,
RN in clinic,
patient
routine meetings monitoring logs
with PCP
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Aubert et al Ann Int
Med 1998;129:605
decreased HbA1c
no increase in adverse events
improved self-reported health status
Non-specific Nurse Case Management
Health System
Community
Resources and Policies
Health Care Organization
Regional health system
developed a guide
referred patients
SelfManagement
Support
trained to
emphasize patient
strengths
Patient/
Caregiver
Gagnon et al, JAGS
1999; 47:1118-1124
Delivery
System
Design
intensive
case mgmt
(home visit
every 6 wks,
monthly
phone calls)
Decision
Support
no clinical
guidelines
consult with
geriatrician
and team
Problem-Centered
Interactions
Clinical
Information
Systems
used a nursing
documentation
program
Case manager
linked to others
Increased hospitalization
No change in functional status
Asthma Resource Center
Health System
Community
Resources and Policies
No links to ER or hosp.
Asthma Resource Center
in hospital
SelfManagement
Support
Standardized
information
Unmotivated
Patient/Family
Premaratne et al BMJ
1999;318:1251-1255
Health Care Organization
Regionalized health system (UK)
Delivery
System
Design
Asthma nurse
working with
practice nurse
who runs
asthma clinic
Decision
Support
Thoracic
Society
Guidelines.
Six teaching
sessions with
nurses
Ineffective
Interactions
Clinical
Information
Systems
Not described
Practice Nurse
working in
isolation
No improvement in QOL, ER use
or anti-inflammatory use
Stages of Coping with Data
• Stage 1: The data are wrong.
• Stage 2: The data are right, but it’s not a
problem.
• Stage 3: The data are right, it’s a
problem, but it’s not my problem.
• Stage 4: The data are right, it’s a
problem, and it’s my problem.
"Ultimately, the secret of quality is love. You
have to love your patients, you have to
love your profession, you have to love
your God. If you have love, you can work
backward to monitor and improve the
system."
Donabedian