Chronic Care Management

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Chronic Care Management

• Sherri Homan RN, PhD
• Missouri Department of Health and Senior Services
• Office of Epidemiology
• Jefferson City, MO

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Chronic Care Management Design

• Pioneered by Edward H. Wagner, MD, MPH and
  colleagues at MacColl Institute for Healthcare
  Innovation at Group Health Cooperative of Puget
  Sound, Seattle Washington
• Supported by Robert Wood Johnson Foundation

Wagner, E.H. (1998). Chronic disease
management. What will it take to improve care
for chronic illness? Effective Clinical
Practice, 1, 2-4. Improving Chronic illness
Care (ICIC) is a national program supported by
Robert Wood Johnson Foundation with direction and
technical assistance by Group Health
Cooperatives MacColl Institute for Healthcare
Innovation.
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Chronic Care Management Premise

• Right Thing
• Right Patient
• Right Time

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Chronic Care Management Model
Wagner, E.H. Chronic Disease Management What
Will It Take to Improve Care for Chronic Illness?
Effective Clinical Practice 1998 12-4.
Permission to reproduce model image granted from
American College of Physicians (ACP), July 7,
2006.
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Mobilize Community Resources

• Patients participate in effective community
  programs
• Form partnerships to fill gaps in needed services
  and avoid duplicating efforts
• Advocate for policies to improve patient care

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Health System Organization of Care

• Improvement at all levels of the organization
• Promote effective strategies
• Open and systematic handling of errors and
  quality issues to improve care
• Provide incentives based on quality of care
• Facilitate care coordination within and across
  organizations

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Self-Management Support

• Patient has a central role in managing health
• Self-management support strategies
• Assessment, goal-setting, action planning,
  problem solving, and follow-up
• Community resources to support self-management

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Delivery System Design

• Define roles and distribute task
• Planned interactions for evidence-based care
• Clinical case management services for complex
  patients
• Regular provider initiated follow-up
• Cultural sensitive care

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Decision Support

• Daily practice of evidence-based care
• Share clinical guidelines and information with
  patients
• Provide professional education
• Integrate specialty and primary care

Agency for Healthcare Research and Quality
National Guideline Clearinghouse http//www.guidel
ine.gov
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Clinical Information Systems

• Timely reminders for providers and patients
• Identify subpopulations for proactive care
• Facilitate individual patient care planning
• Share information
• Monitor outcomes

Registry tracks individuals and populations
Continuous Quality Improvement
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Chronic Care Management Programs

• Comprehensive system change
• Targeting
• Case management

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Primary Care Delivery System

• Traditional
• Provide acute care
• Diagnostic and laboratory services
• Treatment of signs and symptoms
• Prescriptions
• Brief education
• Short appointments
• Patient-initiated follow-up

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Delivery System Redesign

• Traditional
• Provide acute care
• Diagnostic and laboratory Services
• Treatment of signs and symptoms
• Prescriptions
• Brief education
• Short appointments
• Patient-initiated follow-up

• Reconfigured
• Developed processes for CD
• Incentives for making changes
• Extensive patient education to increase
  patients confidence and skills
• Provider-initiated appointments and follow-up
• Evidence-based guidelines and provider
  interaction
• Information Systems

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Targeting Approach

• Correctly assumes a small percent of the
  population accounts for most health care costs
• Possible to reduce cost based on this method
• However, health status changes occur frequently
• Targeting misses a substantial portion of the
  population at risk

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Case Management Approach

• Many programs include
• Brief hospitalization
• Low intensity follow-up care
• Conduct utilization review

Chronic Care Management advocates for Access to
services that are proven to improve outcomes
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Examples Missouris Chronic Health Care
Indicators, BRFSS, 2004

• 69.1 of seniors (age 65) received a flu shot
  in past 12 months
• 65.2 of adults with diabetes test their blood
  sugar at least once daily
• 55.6 of adults with diabetes have participated
  in a course or class to manage their diabetes
• 52.8 of adults (age 50) have ever had a lower
  endoscopy exam

• 39.9 of adults with arthritis have received a
  suggestion from their health care provider to
  exercise or engage in physical activity to help
  their joint symptoms (2003)

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Example Medicaid

• A web-based system to help fee-for-service
  Medicaid patients manage chronic conditions
• Integrate APS Healthcares CareConnection
  application with a chronic care improvement
  program
• Product collaborative medical record
• Accessible to patients, providers and health care
  coaches

The Advisory Board Company. (2006) Missouri
creates web-based chronic care system. iHealth
Beat. Retrieved June 20, 2006 from
http//www.ihealthbeat.org
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Incentives

• Vary across provider organization
• May reduce patient expenses
• May also reduce profitable inpatient care
• Poorly reimbursed preventive services
• Performance related to defined quality goals

Providers - / Provider groups with
full-capitation Health Plans (deliver returns
within 6-12 mo) Purchasers / Employers
Governmental entities
greater incentive to engage in disease
management
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Primary Care Physician Use of Electronic Medical
Records
EuroBarometer survey (N 3,504) U.S.A. survey
(N 377)
Source Harris Interactive Inc. (2002, August
8). European physicians especially in Sweden,
Netherlands and Denmark, lead U.S. in use of
electronic medical records. HealthCare News,
2(16), 1-3. European Union Barometer June, July
2001 (numbers repercentaged by Harris
Interactive) and Harris Interactive Surveys for
U.S.A. in June 2001 and January / February 2001.
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Care Management Processes in Physician
Organizations (N 1,040)
Casalino, L. et al. (2003). External incentives,
information technology, and organized processes
to improve health care quality for patients with
chronic diseases. Journal of the American
Medical Association.
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Chronic Care Management
Overarching Goal
Improved Health Status

• Regular visits with health providers
• Focus on function
• Prevent exacerbations and complications
• Emphasizes self-management
• Ensures access to services proven to improve
  outcomes
• Establishes links through time with information
  systems
• Follow-up initiated by medical provider

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In Summary

• Chronic care management offers improved health
  status for many with chronic diseases
• Chronic illness care should be based on the best
  available evidence
• Need consistent quality measures and additional
  research in the various models