Transformers in Health Care: Integrated Delivery Models

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Transformers in Health CareIntegrated
Delivery Models

• Brian Austin
• MacColl Institute for Healthcare Innovation
• Group Health Cooperative
• Improving Chronic Illness Care,
• a national program of The Robert Wood Johnson
  Foundation

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Usual Chronic Illness Care

• Oriented to acute illness
• Focus on symptoms and lab results
• Patients role in management not emphasized
• Care dependent on providers memory and time
• Interaction often not productive, and frustrating
  for both patient and doctor

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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.

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System Change ConceptsWhy a Chronic Care Model?

• Little guidance for practices wanting to improve
  chronic care because
• Emphasis on physician, not system, behavior
• Characteristics of successful interventions
  werent being categorized usefully
• Commonalities across chronic conditions
  unappreciated.

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Model Development 1993 --

• Initial experience at GHC
• Literature review
• RWJF Chronic Illness Meeting -- Seattle
• Review and revision by advisory committee (40
  members (32 active participants)
• Interviews and site visits with 72 nominated
  best practices
• Model applied with diabetes, geriatrics, asthma,
  CHF, CVD, and depression with over 500 health
  care organizations in national and regional
  collaboratives

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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

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A Recipe for Improving Outcomes

• Learning
• Model

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A Recipe for Improving Outcomes in Chronic Illness
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The Goal of System Changes to Improve Chronic
Illness Care
Productive Interactions
Practice Team
Patient
Continuous healing relationships
characterized by a planned set of
interactionsover time during which the critical
clinicaland behavioral elements of care are
performed reliably
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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
patients self-management. The provider is
viewed as a guide on the side, not the sage on
the stage!
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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
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How would I recognize a productive interaction?
Prepared Practice Team
Informed, Activated Patient
Productive Interactions

• Assessment of disease control, complications, and
  progress in self-management
• Tailoring of clinical management by protocol
• Collaborative goal-setting and problem-solving
• Shared care plan
• Active, sustained follow-up and continuity of care

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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Summary

• Practice changes needed to improve chronic
  illness care similar across conditions
• Multi-faceted interventions with components
  directed at patients, providers and the practice
  most effective
• Practice change will rarely happen without strong
  internal commitment, an action-oriented
  improvement approach, AND outside help.

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For more information

• www.improvingchroniccare.org

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The Future

• The (Chronic) Care Model seems to be holding up,
  and is now in wide circulation.
• Collaboratives are successful with participating
  teams, but will the effects endure and will the
  changes spread beyond collaborative participants?
• The Health Disparities Initiative is THE MODEL
  for large scale primary care improvement. How can
  it help improve the care for all Americans, and
  for people around the world?
• Needs
• 1. A structure that can support local and
  regional collaboratives
• 2. Improvement models that are effective but
  less intensive

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Health Care Organization

• Organization's business plan includes measurable
  goals for chronic illness.
• Senior leaders visibly support improvement in
  chronic illness care.
• Organization uses effective improvement
  strategies aimed at comprehensive system change.
• Provider incentives encourage better chronic
  illness care.

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Community Resources and Policies

• Identify effective programs and encourage
  patients to participate.
• Form partnerships with community organizations to
  support or develop interventions that meet
  patient needs.

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Self-management Support

• Emphasize the patient's central role in managing
  their illness.
• Assess patient self-management knowledge,
  behaviors, confidence, and barriers.
• Provide effective behavior change interventions
  and ongoing support with peers or professionals.
• Assure collaborative care-planning and
  problem-solving by the team.

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Delivery System Design

• Define roles and delegate tasks amongst team
  members.
• Provide access to CLINICAL case management
  services
• Use planned visits to support evidence-based
  care.
• Assure regular follow-up and continuity by the
  primary care team.

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Decision Support

• Embed evidence-based guidelines into daily
  clinical practice.
• Integrate specialist expertise into primary care.
• Use proven provider education modalities to
  support behavior change.
• Inform patients about guidelines pertinent to
  their care.

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Clinical Information System Registry

• A registry includes clinically useful and timely
  information on all patients.
• Information system provides reminders and
  feedback for providers and patients.
• Registry can identify relevant patient subgroups
  for proactive care.
• Registry facilitates individual patient care
  planning.

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Chronic Conditions Breakthrough Series
Participants
Select Topic
Prework
P
Identify Change Concepts
P
P
A
D
A
D
A
D
S
S
S
Planning Group
LS 1
LS 2
LS 3
Natl.C.
Supports E-mail Visits Web-site Phone Assessmen
ts Senior Leader Reports
(13 months time frame)
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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 500 health care systems involved to date
• Both national and regional collaboratives
• Collaboratives frailty in the elderly,
  diabetes, CHF, asthma, depression, arthritis,
  AIDS, CVD