Patientcenteredness and the Chronic Care Model

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Patient-centerednessand the Chronic Care Model

• Ed Wagner MD, MPH
• MacColl Institute for Healthcare Innovation
• Center for Health Studies
• Group Health Cooperative

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Ms. G

• 67 yo widow
• Cares for grandchildren
• 10 yr history of diabetes not well controlled
• Confused about diet, drugs
• Recent onset of CHF leading to hospitalization
• Greater confusion following discharge
• Readmitted with CHF

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Is Ms. G a Rare Case?

• Generally, less than 50 of folks with major
  chronic illnesses receiving accepted treatments
• Less than 50 have satisfactory levels of disease
  control
• Majority of Americans dont feel that the
  chronically get good care

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Whats Responsible for the Quality Chasm?

• Is it unmotivated persons not adhering to
  treatment, yet demanding more??

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The Evidence
1. Motivation and adherence are not genetically
determined behavioral interventions
consistently successful in raising adherence 2.
Noncompliance is not a patient problem it is a
system failure paraphrased from Dr. Paul Farmer
who successfully used complex drug regimens to
treat AIDS and TB in rural Haiti
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The IOM Quality reportA New Health system for
the 21st Century
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Whats Responsible for the Quality Chasm?

• Is it arrogant and ignorant health
  professionals??

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The Evidence

• Much of the variation in care is within a
  practice--i.e., same clinician treating similar
  persons differently
• Surveys reveal majority of (but not all)
  physicians aware of evidence-based treatments for
  major chronic diseases BUT feel ill-prepared to
  manage the educational and emotional needs of the
  chronically ill
• Major problems are inconsistent application of
  knowledge and problems in communication

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Whats Responsible for the Quality Chasm?

• A system that is not working for either patients
  or health professionals??

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Randomized trials of system change interventions
Diabetes

• Cochrane Collaborative Review
• 41 studies, majority randomized trials
• Interventions classified as provider-oriented,
  organizational, information systems, or
  patient-oriented
• 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, 2001241821

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Randomized trials of system change interventions
Heart failure

• 11 randomized trials
• Most reduced hospitalization significantly
• Those that employed a multi-disciplinary team
  more effective than those that used telephone
  contact to coordinate care
• 7/8 examining costs found cost savings

McAlister et al, Am J Med 2001
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IOM Criteria for Quality Healthcare

• Safe
• Effective
• Timely
• Efficient
• Equitable
• Patient-centered

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Patient centered Care

• What is it?

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Emerging Global Definition

• Patient Centered Care
• Explores patients reason for visit, concerns,
  and need for information
• Seeks an integrated understanding of the
  patients world life issues, emotional needs
• Finds common ground on the problem(s) and
  mutually agrees on management
• Enhances prevention and health promotion
• Enhances the continuing relationship with the
  doctor

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Making Patient-centered Care a Reality
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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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The Goal of System Changes to Improve Chronic
Illness Care
Productive Interactions
Practice Team
Patient
a planned set of interactionsover time that
assure the delivery of critical clinical and
behavioral elements of care
And meet patient needs for patient-centeredness
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What characterizes an informed, activated
patient?
They have the motivation, information, skills,
and confidence necessary to effectively make
decisions about their health and manage it
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Patient-centeredness and Chronic Illness

• An informed, activated, competent self-manager
  essential for good outcomes
• Model guided care consistent with definition of
  patient-centered care

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Health Care Organization

• Visibly support improvement at all levels,
  starting with senior leaders.
• Promote effective improvement strategies aimed at
  comprehensive system change.
• Encourage open and systematic handling of
  problems.
• Provide incentives based on quality of care.
• Develop agreements for care coordination.

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Community Resources and Policies

• Encourage patients to participate in effective
  programs.
• Form partnerships with community organizations to
  support or develop programs.
• Advocate for policies to improve care.

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Self-management Support

• Emphasize the patient's central role.
• Use effective self-management support strategies
  that include assessment, goal-setting, action
  planning, problem-solving and follow-up.
• Organize resources to provide support

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Delivery System Design

• Define roles and distribute tasks amongst team
  members.
• Use planned interactions to support
  evidence-based care.
• Provide clinical case management services.
• Ensure regular follow-up.
• Give care that patients understand and that fits
  their culture

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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.

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Clinical Information System

• 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.

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Lets explore two elements in more detail

• Health Care Organization and
• Self-management Support

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Health Care Organization

• Organizations can be patient-centered positive
  patient experience an organizational priority
• ICIC evaluation found that more patient-centered
  organizations performed better in collaboratives

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Self-management Support

• What is self-management?
• The individuals ability to manage the symptoms,
  treatment, physical and social consequences and
  lifestyle changes inherent in living with a
  chronic condition.

Barlow et al, person Educ Couns 200248177
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What Self-management is not
Effective self-management is a primary goal of
patient-centered chronic illness care

• A PREFERENCE OR
• AN OPTION

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Effective self-management Support

• Stand alone programs work,

BUT
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Effects of Self-management Education on Glycemic
Control

• 31 RCTs evaluated effects on HbA1c
• Average 6 contacts and 9 contact hours
• Most often delivered by nurse-dietician-physician
  team
• 2/3 in groups
• Reduction in HbA1c increased with contact time
  (1 for every added 24 hours of contact)

Norris et al, Diabetes Care 2002 251159
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Effects of Self-management Education on HbA1c
Levels across 31 RCTs
Norris et al, Diabetes Care 2002 251159
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Follow-up Activities in Practice Essential to
Sustain the Effect

• The 5 As

• A

• A

• A

• A

• A

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Self-Management in CCM
ASSESS Concerns, Behavior, Values, Preferences
Knowledge
ADVISE About health risks and benefits of change
ARRANGE Specify plan for Additional support
and follow-up
Personal Action Plan 1. List specific goals
in behavioral terms 2. List barriers and
strategies to address barriers 3. Specify
Follow-up Plan 4. Share plan with practice team
and patients social support
AGREE On problems and goals based on patients
interest and confidence in their ability to
change
ASSIST Use problem-solving techniques to
identify barriers and strategies to overcome them
Glasgow RE, et al (2002) Ann Beh Med 24(2)80-87
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ASSESS

• Seeks an integrated understanding of the
• patients world life issues, emotional needs

• Initially
• Concerns, Preferences, Behavior, Confidence,
  Knowledge, Illness Severity
• Follow-up
• Behavior, Confidence and Illness Severity

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• Explores patients reason for visit, concerns,
  and need for information

• Responses to open-ended questions
• Typical patient response cut off after 15-25
  seconds
• If uninterrupted, how long will the
  average patient go on?

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How long does it take a patient to tell their
story?
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Standardizing Assessment

• Use short questionnaires that have proven
  reliability and validity
• Make assessment routine aspect of contacts

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How confident are you that you can control any
symptoms or health problems you have so that they
dont interfere with the things you want to do?
Totally confident
Not at all confident
1 2 3 4 5 6 7 8 9 10
Lorig et al Outcome Measures for Health Education
and other Health Care Interventions, SAGE
Publications, 1996
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ADVISE

• Provide specific information about health risks
  and benefits of change

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Tips on providing advice

• Elicit patients preferred level of information
  to make decisions
• Tailor information to person and their
  environment
• Stick to the science, mute personal biases
• Personalize lab values, health status and how
  behaviors affect outcomes
• Listen more than you talk

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Finds common ground on the problem(s) and
mutually agrees on management
AGREE

• Collaborative problem identification
• Collaborative goal-setting
• Shared decision-making
• Shared care plan

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Tips on Collaborative Goal-Setting

• Begin with elicitation of patients interests and
  priorities (professional advice is already on
  table)
• Differences in opinion require negotiation and
  compromise, not capitulation by either side
• Increase likelihood of progress by 1. Keeping
  goals limited in number 2. Keeping goals modest
  and attainable

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ASSIST

• Identify personal barriers, and use
  problem-solving techniques to identify strategies
  for surmounting them

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Problem Solving

• 1. Identify the problem.
• 2. List all possible solutions.
• 3. Pick one.
• 4. Try it for 2 weeks.
• 5. If it doesnt work, try another.
• 6. If that doesnt work, find a resource for
  ideas.
• 7. If that doesnt work, accept that the problem
  may not be solvable now.

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ARRANGE

• Specify a plan for follow-up

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Does patient-centeredness matter?

• Perceived patient-centeredness more related to
  outcomes than interaction analysis
• Perceived patient-centeredness appears to be
  associated with more satisfied, more enabled, and
  less symptomatic patients

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RAND ICIC EVALUATION

• Studied 51 organizations in four different
  collaboratives
• 2132 BTS patients, 1837 controls with diabetes,
  CHF, asthma
• Data included patient and staff surveys, medical
  record reviews

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RAND Findings

• Organizations made average of 48 changes in 5.8/6
  CCM areas
• Depth of changes averaged 49 (0-100)
• IT received most attention, community linkages
  the least
• Diverse teams with 6-10 members including
  physicians with strong clinical champions did
  best
• CHF pilot patients more knowledgeable and more
  often on recommended therapy, but health outcomes
  no different than controls
• Asthma pilot patients more likely to be on
  controller meds, monitor peak flow, and to have
  an action plan AND reported better QOL
• Diabetic patients had better care processes and
  lower HbA1cs than controls, who also improved

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Contact us

• www.improvingchroniccare.org

thanks