The Chronic Care Model: Implications for HIV Care and Training

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The Chronic Care Model Implications for HIV Care
and Training

• October 1, 2007
• Kathleen A. Clanon, MD, FACP
• Pacific AETC

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Goals for Talk

• Describe the elements of the Chronic Care Model
  and its rationale.
• Describe practical applications of the Chronic
  Care Model in HIV specific settings.
• List possible training settings and audiences for
  which Chronic Care Model content might be
  appropriate.

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The Usual Visit

• Patient is in the room, chart in the slot. Nurses
  and doctors dont confer.
• MD reviews the chart for 30 seconds before
  entering the room.
• Patients goal is to get a form filled out MD is
  worried about new detectable viral load.
• HCM flow sheet is half filled out.
• MD drones through adherence rant.
• Patient leaves, MD notes later that ppd and pap
  were overdue.

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Evolution of HIV Care
1980
2010

• Health Care
• Chronic
• Proactive
• Focus on behavior
• Standardized care
• Practical
• Pt role central

• Disease Care
• Acute
• Reactive
• Focus on dx/rx
• Customized care
• Spiritual
• MD role central

Kathleen Clanon, MD 2007
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Tyranny of the Urgent

• What doesnt get done
• when we do disease
• care instead of
• health care?

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Tyranny of the Urgent What Doesnt Get Done

• Adherence counseling
• Prevention counseling
• Family planning
• Nutrition
• Stress reduction training
• Mental health
• Smoking cessation
• Substance abuse treatment
• Vaccinations
• Cancer screening
• HCV treatment

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Hepatitis A B Vaccination Practices for
Ambulatory Patients with HIV-Infection
Design
Results

• Methods- 9 Clinic (HOPS) Sites- N 1071 in
  study- Analysis of HOPS data base

From Tedalid EM et al. Clin Infect Dis
2004381478-84.
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One Example Smoking

• Many PWHIV smoke (52 vs 23 in gen pop)
• Smokers on HAART have morbidity (ADC 36) and
  mortality (53)compared to nonsmokers.
• Well-documented programs and interventions for
  smoking cessation are available.
• Does your clinic have a smoking cessation program
  for HIV positive patients?

Feldman J Am J Public Health 200696(6)1060
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Not Just HIV Preventive Care Quality

• Over 4000 patient visits by 138 family physicians
• Patients were up to date on
• 55 of routine screening tests
• 24 of immunizations
• 9 of health behavior counseling
• Stange et al. Prev Med 200031167

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Do the Math

• A primary care physician with a panel of 2500
  average patients (not HIV) would need to spend
• 7.4 hours per day to do all recommended
  preventive care.
• Yarnall et al. Am J Public Health 200393635
• 10.6 hours per day to do all recommended chronic
  care.
• Ostbye et al. Annals of Fam Med 20053209
• Slide adapted from Bodenheimer.

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Impact of the Aging Epidemic More Chronic
Illnesses

• Prevalence of other chronic illnesses in VA
  patients with HIV
• Hypertension 40
• Hyperlipidemia 22
• Diabetes 17

Fultz SL et al, CID 2005 Sep 1 41738-43
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HIV Providers Comfort Treating Other Chronic
Illnesses
Fultz SL et al, CID 2005 Sep 1 41738-43.
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What Do These Data Demonstrate?

• Overfocus on the clinician-patient dyad as the
  unit of care.
• Underutilization of the team (esp. the patient)
  in care.
• Insanity of the 15 minute visit.

Slide adapted from Bodenheimer.
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My Favorite Quote from the Government

• Improvements in care cannot be achieved by
  further stressing current systems of care. The
  current systems cannot do the job. Trying harder
  will not work.
• IOM 2001 Crossing the Quality Chasm

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Genesis of the CCM Why Research Results and Real
Life Dont Match

• Rushed practitioners not following established
  practice guidelines
• The gap between knowing and doing.
• Lack of care coordination
• Lack of active follow-up to ensure the best
  outcomes
• Patients not trained to manage their own
  illnesses successfully

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History of the Chronic Care Model

• Developing the Model
• Improving Chronic Illness Care Program, MacColl
  Institute for Healthcare Innovation, Seattle.
• RWJF Chronic Illness Meeting
• Developing a Change Strategy
• IHI Breakthrough Series, Dallas 1999
• Disseminating the Practice
• Model applied with diabetes, geriatrics, asthma,
  CHF, CVD, HIV/AIDS, and depression in 500 health
  care organizations via collaboratives.

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
Practice Level
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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HIV Chronic Care Model
All Parts
Community
Food bank, volunteers, child care.
RWHATMA Continuum of Care
CAREware, labtracker Aries
Case man. Integrate MH care
AETC training Dissem DHHS Guidelines
Client advocacy, peer mentoring
Informed, Activated Patient/Client
Prepared, Proactive Care Team
Productive Interactions
Improved Outcomes
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Domains of the Chronic Care Model

• Self-management Support
• Patient sets goals and is in charge of care.
• Education focuses on problem-solving skills.
• Peer mentoring and support.
• Adherence and prevention programs.
• Community Involvement
• Form partnerships with ASOs.
• Address stigma and myths.
• Delivery System Design
• Planned and group visits.
• Case management.
• Integrating mental health/subs abuse/medical
  care.
• .

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Domains of the Chronic Care Model

• Decision Support (Provider Knowledge and
  Behavior)
• Embed guidelines into daily care.
• Share guidelines with patients, case managers
• AETC activities
• Clinical Information System
• Provide reminders of care for providers and pts.
  
• Feed aggregate data into CQI system.
• Share appropriate info between partner orgs.
• Health Care Organization/Grantee
• Encourage open handling of errors.
• Support improvement at all levels of the org.
• Set and monitor goals in chronic care outcomes
  for the organization.

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Does the CCM Improve Outcomes?

• Its a model, not a single intervention.
• Meta-analysis of 112 studies of four chronic
  illnesses asthma, CHF, Type II DM, and
  depression.
• Interventions with at least one CCM element had
  consistently beneficial effects on clinical
  outcomes and processes of care across all
  conditions studied.
• Tsai, A.C. et al A meta-analysis of
  interventions to improve care for chronic
  illnesses. AJ Managed Care 8/05

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HIV Why Might the CCM Work?

• Dangerous chronic illness with available,
  effective treatment.
• Treatment is difficult and lasts over years and
  decades.
• Treatment requires sustained behavior change on
  part of patient.
• Gap between knowledge and outcomes.

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CCM in Action Two Dimensions

• Patient Self-Management
• Delivery System Design

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

• Goal setting
• Assessing conviction and confidence
• Action planning
• Peer mentoring and advocacy

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Can Our Patients Self-Manage?

• Patients with chronic conditions self-manage
  their illness. This fact is inescapable. Each
  day, patients decide what they are going to eat,
  whether they will exercise, and to what extent
  they will consume prescribed medications. Bod
  enheimer, et al 2002 JAMA 288(19) 2470

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Traditional Patient Education vs.Self-Management
Education
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Action Plan (Example)

• 1. Goals Something you WANT to do
• Begin exercising_______
• 2. Describe
• How Walking________
• Where Around the block
• What 2 times Frequency 4 x/wk
• When After dinner____
• 3. Barriers Have to clean up bad weather
• 4. Plans to overcome barriers
• Ask kids to help get rain gear
• Conviction 8 Confidence 7 ratings
• (0-10)
• 6. Follow-Up Next visit 2 months

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Delivery System Design

• Planned visits
• Expanding staff roles
• Using information systems
• Group visits
• Case management
• Integrated care One-stop-shop

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Planned Medical Visits

• an encounter that focuses on overall patient
  goals and other aspects of care that are not
  usually delivered during an acute-care visit.
• AAFP, June 2005

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Planned Medical Visits

• Standing meeting of staff (no chairs, no
  donuts) at beginning of day to review each
  patient
• Team members are alerted and on the same page
  (adherence educators, case managers, etc.) Tasks
  are shared.
• Print out of what HCM the pt needs is on the
  front of the chart with overdue items flagged.
• Materials are in room(vaccines, pap materials,
  forms and education materials).

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Using Staff Differently

• May be peers, health educators, M.A.s. They take
  the lead on health promotion.
• Meet with pts pre-, during-, or post- the
  clinician visit.
• Advantages are
• Patients connect with staff differently than with
  M.D.
• Cheaper staff can take more time with pts.
• Staff like it!

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Group Visits

• Medical visits, scheduled for 2.5 hours.
• 10-12 patients scheduled.
• Clinician, case managers, adherence educators,
  benefits advisers all present.
• Starts with education, group questions. Focus on
  self-management, prevention and HCM.
• Providers pull pts out for brief one-on-ones as
  group session continues.

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Implementing the CCM What Are the Barriers?

• Time
• Turf
• Trust
• Turnover

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Implementing the CCM What Are the Barriers?

• Payers may not reimburse for group work or prep
  work
• Difficulty of changing big systems
• HIPAA
• Tradition of individualism in medicine. (We are
  the biggest obstacle.)

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What Are the HIV-specific Barriers?

• Stigma and disclosure concerns
• No patient-accessible measure of daily health
  (similar to glucose or peak flow)
• Groups most affected by HIV have social,
  educational challenges
• Our pts deal with chaos low show rates and
  crises mean staff need to be consistent and
  protect the planned visit time.

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Resources

• Websites
• www.improvingchroniccare.org
• www.collaborativeselfmanagement.org
• www.nqc.org
• Contacts
• Kathleen A. Clanon, MD, FACP
• kclanon_at_jba-cht.com