Transcript The Patient's Role In Chronic Illness Care

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
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.
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
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
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.”
What’s Responsible for the Quality Chasm?
• A system oriented
to acute disease
that isn’t working
for patients or
professionals
What kind of changes to practice
systems improve care?
Randomized trials of system change
interventions: Diabetes
Cochrane Collaborative Review
• 41 studies, majority randomized trials
• Interventions classified as provider-oriented,
organizational, information systems, or patientoriented
• 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
The Effectiveness of QI Strategies: Findings from a Recent
Review of Diabetes Care
Shojania, K. G. et al. JAMA 2006;296:427-440.
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
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
What distinguishes good chronic
illness care from usual care?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
• 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
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.
Self-Management Support
Goal
To help patients take a more active role and
be more competent managers of their
health and healthcare.
Community Resources and
Policies
Goal
To help patients access effective and useful
services and resources in the surrounding
community.
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.
.
Delivery System Design
Goal
To organize practice staff, schedules and
other systems to assure that all patients
receive planned, evidence-based care.
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.
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.
Health Care Organization
Goal
To assure that practices within the
organization have the motivation, support
and resources needed to redesign their
care systems.
Does the CCM Work?
The Evidence
Base
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
1: RCTs of interventions to
improve chronic care results
Studies in other conditions confirm that the
elements found effective in diabetes care
apply to other chronic conditions as well.
2: Studies of the Relationship between
Organizational Characteristics and Quality
•
Studies measure adherence to the CCM via selfassessment 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.
Several studies have demonstrated a relationship
between practice characteristics consistent
with the CCM and performance
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
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
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
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.
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
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 clinicwide outcomes for another year or two.
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
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
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
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
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 nonphysician staff to improve patient care
• Practice isolation
• Fee-for-service reimbursement that doesn’t reward high
quality care, in fact discourages it
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?
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?
Contact us:
•www.improvingchroniccare.org
thanks
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
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
FACTS AND FICTIONS
1. Diabetes is the leading cause of adult blindness,
amputations and kidney failure. True or false?
________________________________________
A. False. Poorly controlled diabetes is the leading
cause of adult blindness, amputations and kidney
failure.
Setting the Stage for Change
Differences Between Acute and
Chronic Conditions
ACUTE
CHRONIC
Beginning
Rapid
Gradual
Cause
Usually one
Many
Duration
Short
Indefinite
Diagnosis
Commonly
Often
accurate
uncertain
Often decisive Often limited
value
Cure common Cure rare
Diagnostic
tests
Treatment
Differences Between Acute and
Chronic Care Roles
Role of
Professional
Role of
Patient
Lorig 2000
ACUTE
Select and
conduct
therapy
CHRONIC
Teacher/coach
and partner
Follow orders
Partner/ Daily
manager
Symptom Cycle
Disease
Fatigue
Tense muscles
Vicious
Cycle
Depression
Stress/Anxiety
Anger/Frustration/Fear
Persuasion Techniques
•
•
•
•
•
•
•
•
Agree that speaker should make the change
Explain why the change is important
Warn of consequences of not changing
Advise speaker how to change
Reassure speaker that change is possible
Disagree if speaker argues against change
Tell the speaker what to do
Give examples of others (other patients, peers,
celebrities) who have made similar healthy changes
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 selfmanagement
Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated to live a
long, healthy life
3. Help your patient determine exactly what they
might want to change
4. Develop a reasonable, detailed action plan
Self-Management in office practice
ASSESS :
Beliefs, Behavior & Knowledge
ARRANGE :
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
Personal Action Plan
reminders
1.
2.
3.
4.
ADVISE :
Provide specific
Information about
health risks and
benefits of change
List specific goals in behavioral terms
List barriers and strategies to address barriers
Specify Follow-up Plan
Share plan with practice team and patient’s social
support
ASSIST :
Identify personal
barriers, strategies, problem-solving
techniques and
social/environmental
support
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
AGREE:
Collaboratively set
goals based on patient’s
interest and confidence
in their ability to change
the behavior
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
Ecological Model of Health Behavior
Community, Environment, Policy
Systems, Organizations, Businesses
Family, Friends
Peer Groups
Individual
Promotoras/Community Health Workers
Peer Led Workshops
Outreach
Organizations
Partnering Relationships
involvement
collaborating
cooperating
commitment
coordinating
resources
networking
Environment and Policy
Walkable Neighborhoods/ Cyclovia
It Takes a Region
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
The Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Delivery
System
Design
Informed,
Productive
Empowered Interactions
Patient
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
You are
here
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.
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
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
A Recent Product Comparison
CHCF’s Better Ideas Conference 2006
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!
Organizational characteristics of Medicare
Managed Care Plans by Diabetes Quality
High performing
Plans
Low performing
Plans
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
Characteristic
Fleming et al. Am J Managed Care 2004 10: 934
P
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
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.
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
A Patient View of an EMR
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.
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
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
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
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
Effective educational methods
Interactive, sequential opportunities in small
groups or individual training
• Academic detailing
• Problem-based learning
• Modeling (joint visits)
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
The Patient as Partner
Principles of CIS &DS
Other Choices for Patient Decision
Support
PBGH Evaluation of Consumer Decision Support Tools June 2007
Ways to share guidelines with
patients
• Stoplight tools
• Expectations for care
• Wallet cards
• Web sites
• Workbooks
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Delivery
System
Design
Informed,
Productive
Empowered Interactions
Patient
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes