Transcript The Patient's Role In Chronic Illness Care

The Chronic Care Model
Mike Hindmarsh
Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation
California Chronic Care Learning Communities
Initiative Collaborative
Oakland, CA
November 2-3, 2004
ICIC Website:
http://www.improvingchroniccare.org
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%
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
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 Burden of Chronic Illness on The Acute
Care System
The Average Patient with Diabetes has:
Additional Diagnoses*
45%
Functional Limits**
50%
> 2 Symptoms***
35%
Poor 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%)
Diabetes Care in the U.S.
Harris. Diab Care 2000;23:754-8
100%
80%
60%
40%
20%
0%
ot
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u
Fl
am
Ex
e
Ey
se
U
SA
A
0
13
L<
LD
90
0/
14
P<
B
<8
1c
bA
H
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
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.”
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
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
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 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
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
Chronic Conditions Collaboratives
• Mechanism for spreading health system change
via the Chronic Care Model
• 13 month intensive improvement efforts working
with multiple teams from varying health systems
• Over 1000 health care systems involved to date
• Both national and regional collaboratives
• Collaboratives: frailty in the elderly, diabetes,
CHF, asthma, depression, arthritis, AIDS, CVD,
prevention
Regional Collaboratives (past & present)
• Washington State: Diabetes I, II, III
• Alaska: Diabetes
• Oregon: Diabetes, CHF
• Chicago: Diabetes
• Vermont: Diabetes I, II
• New Mexico: Diabetes
• Wisconsin: Diabetes I, II
• Arkansas: Diabetes
• Nevada: Diabetes
Regional Collaboratives (cont’d)
• Maine: Diabetes
• Rhode Island: Diabetes I, II
• Arizona: Diabetes
• North Carolina: Diabetes
• New York: Asthma and Prenatal Care
• Indiana Chronic Disease Management Program
• New York Health and Hospital: Diabetes & CHF
• British Columbia: CHF and Diabetes
Successes of Teams in Collaboratives:
The Benefit of Organized Chronic Care
• 1.5 - 2 times as many patients with major
depression will be recovered at six months
• Inner city kids with moderate to severe asthma
have 13 fewer days per year with symptoms
• Readmission rates of patients hospitalized with
CHF will be cut nearly in half
• HbA1cs, LDLs and BPs are reduced
RAND Evaluation questions
– Do organizations in a collaborative learning
environment change their systems for
delivering chronic illness care?
– Does implementing the Chronic Care Model
improve processes of care and patient health
– http://www.rand.org/health/ICICE
RAND Findings Comparing Collaborative
Participant Patients with Controls
• Decreases in HbA1c for patients with diabetes
• Significant increase in patient reports of
counseling, education and improved lifestyle for
CHF
• Significant improvement in QOL for patients with
asthma
• Significant increase in patients on controller
medications
Contact us:
•www.improvingchroniccare.org
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