1 elective 2 chronic care introduction
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Chronic Care Model and managment
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1 elective 2 chronic care introduction
- 2. 2 Paradox: We are still practicing acute care medicine in a world of chronic disease 19th century models at the dawn of the 21st century
- 3. 3 Some Ideas are Just Wrong
- 4. 4 No Chronic Conditions 55% One or More Chronic Conditions 45% People with One or More Chronic Conditions Use: 72% of All Physician Visits 76% of All Hospital Admissions 80% of Total Hospital Days 88% of All Prescriptions 96% of All Home Care Visits Chronic Care: A Universal 21st Century Challenge WHO has developed a plan for worldwide attention to chronic care
- 5. 5 II. The Chronic Care Model
- 6. 6 Evidence-based Clinical Change Concepts A Recipe for Improving Outcomes Learning Model System Change Concepts 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? Model for Improvement Act Plan Study Do System change strategy Select Topic Planning Group Identify Change Concepts Participants Prework LS 1 P S A D P S A D LS 3LS 2 Action Period Supports E-mail Visits Web-site Phone Assessments Senior Leader Reports Event A D P S (12 months time frame)
- 7. 7 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.
- 8. 8 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Improved Outcomes
- 9. 9 Essential Element of Good Chronic Illness Care Informed, Activated Patient Productive Interactions Prepared Practice Team Productive means that the work of evidence-based chronic disease care gets done in a systematic way, and patient needs are met.
- 10. 10 What characterizes an “informed, activated patient”? Informed, Activated Patient They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it. sufficient information to become a wise decision-maker related to their illness understanding the importance of their role in managing the illness.
- 11. 11 What characterizes a “prepared” practice team? Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care. organized, trained, and equipped to conduct productive interactions
- 12. 12 • 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. Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction? 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.
- 13. 13 Productive Interactions Informed, Activated Patient and Caregiver Prepared, Proactive Practice Team Health System Health Care Organization Self- Management Support Delivery System Design Decision Support Clinical Information Systems Community Resources and Policies Improved Outcomes Wagner, 1996 Elements: 1. Self-Management support: Empower and prepare patients to manage their health and health care. 2. Delivery system design: Assure the delivery of effective, efficient clinical care and self- management support. 3. Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences. 4. Clinical information system: Organize patient and population data to facilitate efficient and effective care. 5. Community: Mobilize community resources to meet needs of patients. 6. Health care organization: Create a culture, organization, and mechanisms that promote safe, high-quality care.
- 14. What Are Chronic Diseases? >A chronic disease persistent or recurring disease, usually affecting a person for three months or longer. • are non communicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely.
- 15. Chronic disease vs Chronic illness • often used interchangeably in the clinical literature and in health services policy and organization, they convey different meanings; • Chronic disease is defined on the basis of the biomedical disease classification, and includes diabetes, asthma, and depression. • Chronic illness is the personal experience of living with the affliction that often accompanies chronic disease. It is often not recognized in health systems, because it does not fit into a biomedical or administrative classification. 15
- 16. 16 Components of Chronic Disease Care • Patient experience of care • Care delivery teams • Organizations within which delivery teams and patients interact • Regulatory and payment environment
- 17. 17 Some Ideas Need More Thought
- 18. 18 Characteristics of Chronic Disease: • Last a lifetime • Accumulate with age • Generally progressive • Life-shaping • Different meaning in different cultures
- 19. 19 Goals of Chronic Disease Care 1. Manage the disease to reduce exacerbations. 2. Prevent the transition from impairment to disability, and from disability to handicap. 3. Encourage patient to play an active role in managing his/her disease but avoid allowing the disease to dominate the person’s life. 4. Provide care in a culturally sensitive manner. 5. Integrate medical care with other aspects of life without medicalizing those aspects.
- 20. Case Study • Terri Schiavo Case Reflection: a. If you were Terri Schiavo’s husband what will be your decision on the case of your wife? b. Is the family of Terri Schiavo selfish ? c. Did the US supreme court made the right decision? d. Discuss the case of Terri Schiavo using the CCM (Chronic Care Model) 20
- 21. 21 A Lot Depends on Interpretation
- 22. 22
- 23. 23 What is involved • New definitions – Prevention – Patients’ roles – Time – Place • New approaches – Professional roles – Expectations – Information technology – Management
- 24. 24 Definitions: Prevention • Prevent exacerbations • Reduce expensive utilization • Prevent dysfunction • Avoid iatrogenic effects
- 25. 25 Definitions: Patients’ Roles • 365/24/7 – Shared responsibility – Shared risk • Ongoing communication • Shared decision making – Need better information – Need time
- 26. 26 Definitions: Time • Episode vs. Encounter • Pay-off horizon – Up-front investment recovered over time • Manage by change, not routine – Scheduling appointments – Length of appointments
- 27. 27 Definitions: Place • Chronic care occurs across locations • The same care can be provided in different settings
- 28. 28 What is involved • New definitions – Prevention – Patients’ roles – Time – Place • New approaches – Professional roles – Expectations – Information technology – Management
- 29. 29 New Approaches: Professional Roles • Downward delegation – non-physicians – non-professionals • Primary care – simple cases – complex cases • New teams – Specialists, nutritionist & therapist
- 30. 30 New Approaches: Expectations • Cure vs. Management • Measuring success – actual vs. expected
- 32. 32 New Approaches: Management Case Management Variations • Eligibility management – not all health practitioner not all patient • Care coordination – all areas are involved • Utilization management – proper resources proper patient • Disease management – Often independent – Targeted • Chronic care management -
- 33. 33
- 34. 34 New Approaches: Management • Patient self-care – Education – Motivation – Attitudinal change • Nurse-patient partnerships – Information based – Patient empowering
- 35. 35 New Approaches: Information Technology Problems with too much as well as too little information. Need to focus provider & patient attention on salient data • Just in time information • Structured information – Clinical glidepaths
- 37. 37 Clinical Glidepath • A CLINICAL GLIDEPATH is a way to observe one or more parameters of a patient’s condition on a regular basis to be able to compare the observed state with the expected state. • It is a tool to improve communication between patients and primary care providers. • If the patients stays within the expected course, nothing need be done. • But if the patient’s clinical course deviates, this change should trigger immediate closer attention to ward off a problem while it is early.
- 39. 39 Strategies for Improving Chronic Disease Care • Interdisciplinary team care • Group care – nurses or doctors • Information systems – Electronic medical record – Computerized physician order entry – Clinical tracking systems • Mobile computing
- 40. 40 Evidence of Success • Some encouraging signs but no clear trend • Increased clinic visits and reorganization associated with fewer hospitalizations and urgent care visits in; COPD Diabetes Pneumonia Chronic renal failure CHF Depression Angina Ashton, NEJM, 2003
- 41. 41 Quality care related to better survival among vulnerable older patients Higashi, Ann Int Med, 2005 Self-management programs for diabetes and hypertension improve outcomes Chodosh, Ann Int Med, 2005 Medication adherence reduces hospitalizations for diabetes, hypertension, hypercholesterolemia and CHF Sokol, Med. Care, 2005
- 42. 42 “The prevailing evidence appears to be that while disease management programs improve adherence to practice guidelines and lead to better control of the disease, their net effects on health care costs are not clear.” CBO, 2004
- 43. 43 Payment Issues • Providers expect to be paid for what they do • Who will invest in primary care • Medicare (PHILHEALTH) – Expand coverage to include new services • Monitoring • Counseling – Share savings from decreased inpatient/ER utilization – Pay more per visit for fewer visits – Pay for episodes instead of incidents – Pay for outcomes
- 44. 44 Conclusions • Chronic disease is here to stay • More must be done to bring the health care system into alignment • There is good scientific evidence to show better care is possible • Managed care does not seem to be the magic carpet – If managed care is to have any success, need better case mix payment system • Changing the payment system is necessary but not sufficient
- 45. 45 How You Implement Is Important
Notes de l'éditeur
- As we began to look at this literature it became clear that a number of different ingredients are needed to improve the quality of chronic illness care. First of all, there has to be a clear understanding of the clinical interventions that make a difference. Usually those are represented in evidence-based guidelines. You then need ideas for changing the system (such as the CCM) to increase the likelihood that those evidence-based clinical changes get done. But what we’ve found is that such change is extremely difficult. So you need an approach to changing systems, such as the Model for Improvement used by the Institute for Healthcare Improvement. These three provide the intellectual foundation for quality improvement. The final piece that is needed is a learning model that permits busy practices to take this intellectual foundation and make it real, and for us that has been the Breakthrough Series Collaborative.
- In the past, deficiencies were attributed to bad physicians who just didn’t do the right thing. Instead, the emphasis needs to be on the system and the care it delivers. The literature hadn’t been organized in a way that made it easy to understand how researchers achieved better results. Research is primarily condition-specific because of funding sources. We need to be able to provide care in a way that works for patients with asthma, depression or multiple sclerosis. We need to do this for our own sanity and for our patients’, who can’t be expected to deal with a system where they have five case managers, seven providers and charts in every one of those places.
- Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (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 are at the practice level. Some aspects of larger healthcare organizations 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 the most visible part of care to the patient, followed by 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
- 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.
- The other side of the productive interaction is a practice team that is organized, trained, and equipped to conduct productive interactions.
- 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.