Transcript The Patient's Role In Chronic Illness Care

What will it Take to Improve Care for
Chronic Illness for the Population?
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
Step 1: Find the causes of inadequate care.
IOM Quality Chasm Report:
“The current care systems
cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”
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 during high risk periods,
and
 Coordination of care across settings and professionals
What’s Responsible for the Quality Chasm?
• A system oriented to
acute disease that
isn’t working for
patients with longterm care needs or
the professionals
caring for them
Step 2: Select a strategy
Three Options:
1. Assume that competition and computers will
improve care
2. Direct to patient disease management
3. Improve medical care by changing
care systems
Why is it critical that we change care
systems?
• The human and financial costs of chronic
disease are heavily determined by the level and
duration of disease control
• Without high quality medical care, disease
control measures like HbA1c, BP, LDL tend to
plateau or slowly worsen over time
• It is difficult (maybe impossible) to deal with the
many attitudinal, behavioral and pharmacologic
issues associated with poor control in currently
designed care systems.
Why?
1. Some patients simply fall between the cracks and many
practices have neither the data nor mechanisms to find them.
2. If care consists largely of patient-initiated visits for new
problems, there usually isn’t time to optimize:
• Patient understanding and involvement
• Medication adherence
• Self-management competence
• The drug regimen
3. Many patients with less than optimal control need more
intensive management and follow-up than practices usually
provide
What kind of changes to practice systems
improve care?
 better use of non-physician team
members,
 planned encounters,
 modern self-management
support
 Care management for high risk
 Links to effective community
resources
 guidelines integrated into care
 enhancements to information
systems (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
Current status of Chronic Care Model
• National measurement and pay for
performance programs – NCQA
• State initiatives – California, Vermont, Pennsylvania,
North Carolina, etc.
• New models of Primary Care
AAFP – combines CCM, medical home, and pay for
coordination and performance
ACP – “advanced medical home” has same three
ingredients
Does the CCM Work?
The Evidence
Base
Organizing the Evidence
1.
Randomized controlled trials (RCTs) of
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: Randomized Controlled Trials of
Interventions to Improve Chronic Care
• Most reviews are disease specific.
• Reviews and meta-analyses tend to
focus on individual components rather
than combined effects.
• Diabetes reviews played an important
role in CCM development.
1: Randomized trials of system change
interventions: Diabetes
Cochrane Collaborative Review and JAMA Re-review
•
About 40 studies, mostly randomized trials
•
Interventions classified as decision support, delivery system design,
information systems, or self-management support
•
19 of 20 studies that included a self-management component
improved care.
•
All five studies with interventions in all four domains had positive
impacts on patients.
Renders et al, Diabetes Care, 2001; 24:1821
Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910
1: RCTs of interventions to
improve chronic care results
• “Complex,” “integrated care,” programs
show positive effects on quality of care
• Consistently powerful elements include:
team care, case management, selfmanagement support
1: An Example of a Meta-analysis of
interventions to improve chronic illness
• Includes 112 studies, most RCTs (27 asthma,
21 CHF, 33 depression, 31 diabetes)
• Interventions that contained one or more
CCM elements improved clinical outcomes
(RR .75-.82) and processes of care (RR 1.301.61)
• No superfluous element
• Didn’t study interactive effects
Tsai AC, Morton SC, Mangione CM, Keeler EB. Am J Manag
Care. 2005 Aug;11(8):478-88.
2: Studies of the Relationship between
Organizational Characteristics and Quality
Studies by CMS, NCQA and others have
shown strong correlations between
practice consistency with the CCM and
diabetes performance indicators.
3: Evaluations of the Use of CCM
in Quality Improvement
• Largest concentration of literature
• Includes RAND Evaluation of ICIC
• Wide variety in quality and type of
evaluation designs
• Majority of studies focus on diabetes
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
• 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 (2)
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: Non-RAND Evaluations of CCM
Implementation
• In general, those studies with greater fidelity to
the CCM showed greater improvements.
• All but one showed improvement on some
process measures.
• Most showed improvement on outcomes and
empowerment measures, as well.
• Recent evaluation shows cost-effectiveness of
collaborative participation-- $33,000/QALY
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
• All showed positive effects on process, and
all but one on outcomes
Step 3—Reach the Majority of
Practices
Lessons learned in chronic illness care
improvement
• Chronic care collaboratives have demonstrated that
practices can make these changes and improve care
• Mostly reaching early adopters
• Practice redesign is very difficult in the absence of a
larger, supportive “system”, especially for smaller
practices
• How to help isolated small practices where 80% of
Americans receive their care?
• How do the VA, Kaiser achieve high quality?
But, the VA and
Kaiser are
organizations with
leaders, money, fairly
clear business goals,
and staff who share
those goals. Is there
anything analogous in
the community?
Organizational factors supportive of high quality
chronic care*:
• Strategic values and leadership that support long term
investment in managing chronic diseases
• Investment in information technology systems and other
infrastructure to support chronic care
• Use of performance measures and financial incentives to
shape clinical behavior
• Active programs of Quality Improvement based on
explicit models
*King’s Fund Study
What’s needed to improve chronic
illness care for the population?
• Commitment and
Leadership
• Measurement (and
incentives)
• Infrastructure support
• Active program of practice
change
Step 4—Build a regional healthcare “system”
But, who might do it, and what would they do?
A Framework for Regional Quality
Improvement
• Data sources were a literature review, interviews
with leaders of major coalitions directed at
quality, and lessons learned in helping launch the
PSHA
• The goal is to provide a visual summary of what
leading coalitions were doing—I.e. not an
evidence-based model
Leadership
A Framework for
Regional Quality
Improvement
Contact us:
•www.improvingchroniccare.org
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