Chronic Disease Initiative

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Chronic Disease Initiative The Care Model

• Pradeep G. Kumar MD
• Gerald L. Ignace Indian Health Center
• September 19th 2007

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Summary

• Gerald L. Ignace Indian Health Center
• The current practice of Medicine
• IHS Directors initiative
• Care Model
• An example of change at our clinic

3
Summary

• Gerald L. Ignace Indian Health Center
• The current practice of Medicine
• IHS Directors initiative
• Care Model
• An example of change at our clinic

4
(No Transcript)
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Background Information

• Location
• Milwaukee, WI
• Population served
• Southeastern Wisconsin
• 1,985 unduplicated persons
• 5,212 AIs in Milwaukee according to US census
  Bureau 2000
• Number of Sites
• 1 school nurse services at the Indian Community
  School

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Services Profile

• Family Practice, Pediatrics, Podiatry, Mental
  Health/AODA/family counseling
• Social Services, Career Center, Enabling Services
• Programs DREAM (Diabetes Reflections Empowerment
  And Me-education, fitness, nutrition), WOLFE
  (Work Out Low Fat Elder program), Baby Think It
  Over (Youth Group)
• No Contract Health Service Dollars
• No RPMS yet!

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Summary

• Gerald L. Ignace Indian Health Center
• The current practice of Medicine
• IHS Directors initiative
• Care Model
• An example of change at our clinic

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(No Transcript)
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Every system is perfectly designed to get the
results it gets. - Donald Berwick, IHIs
President and CEO
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Chronic Illness in America

• More than 125 million Americans suffer from one
  or more chronic illnesses and 40 million limited
  by them.
• Despite annual spending of nearly 1 trillion and
  significant advances in care, one-half or more of
  patients still dont receive appropriate care.
• Gaps in quality care lead to thousands of
  avoidable deaths each year.
• Best practices could avoid an estimated 41
  million sick days and more than 11 billion
  annually in lost productivity.
• Patients and families increasingly recognize the
  defects in their care.

Anderson G, Horvath J. The Growing Burden of
Chronic Disease in America, Public Health
Reports, MayJune 2004
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Number of Chronic Conditions per Medicare
Beneficiary
95
63
Partnership for Solutions, Johns Hopkins
University, http//partnershipforsolutions.org/
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The IOM Quality report A New Health System for
the 21st Century
http//www4.nas.edu/onpi/webextra.nsf/web/chasm?Op
enDocument
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The IOM Quality Chasm Report Conclusions

• The current care systems cannot do the job.
• Trying harder will not work.
• Changing care systems will.

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To Change Outcomes Requires Fundamental Practice
Change

• Reviews of interventions in several conditions
  show that effective practice changes are similar
  across conditions.
• Integrated changes with components directed at
• influencing physician behavior,
• better use of non-physician team members,
• enhancements to information systems,
• planned encounters
• modern self-management support, and
• care management for high risk patients

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Chronic DiseaseThe Need for a New Clinical
Education

• Facts about chronic care
• The practice of chronic care medicine requires a
  different approach
• The role of the patient
• Evidence for a new approach

Holman H. JAMA Vol 292, No.9, Sept 1, 2004
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Summary

• Gerald L. Ignace Indian Health Center
• The current practice of Medicine
• IHS Directors initiative
• Care Model
• An example of change at our clinic

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IHS Directors 2005 Initiatives

• Health Promotion Disease Prevention
• Focus on best practices and promote
  standardization of interventions
• Behavioral Health
• Reduce uncontrolled depression/sequelae
• Chronic Disease
• Use best practices in medical and social
  management of disease

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Chronic Disease Initiative

• AIM
• Improve the health status of those affected by
  chronic disease and reduce the prevalence and
  impact of those diseases by adapting and
  implementing the Chronic Care Model.

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The Institute for Healthcare Improvement

• International leader of creating change and
  improvement in healthcare
• Non-profit organization devoted to improving
  health care for all
• Commitment to driving improved outcomes for
  underserved and vulnerable populations
• Developing innovations and facilitating broad
  scale adoption of sound changes to improve health
  care for thousands of patients served by IHS

www.ihi.org
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• Innovations in Planned Care
• for
• The Indian Health System
• (IPC - IHS)

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IPC-IHS

• The Chronic Care Workgroup has developed an
  Innovations in Planned Care for the Indian Health
  System (IPC-IHS) Collaborative to support pilot
  projects that will facilitate system-wide
  implementation of the Chronic Care Model

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IPC-IHS

• Purpose of pilot projects is to demonstrate that
  system changes can improve patient outcomes
  across multiple chronic illnesses in a
  cost-effective manner.
• Pilot sites will
• Test and implement innovative changes in the
  delivery of care
• Share lessons learned to facilitate spread
  throughout the IHS

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IPC-IHS

• 14 national teams
• Indian Health Service (Federal)
• Tribal
• Urban

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IPC Pilot Sites
Eastern Aleutian Tribes
FC Potawatomi G Ignace
Rapid City
Warm Springs
Wind River
Indian Health Council
Chinle Gallup
Albuquerque
Cherokee
Whiteriver
Sells
Mississippi Choctaw
Tribal IHS Federal Sites Urban
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Summary

• Gerald L. Ignace Indian Health Center
• The current practice of Medicine
• IHS Directors initiative
• Care Model
• An example of change at our clinic

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The Care Model

• Model for Change --
• Care Model

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A Recipe for Improving Outcomes
System change strategy
Learning Model
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
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The Care Model
Wagner EH. Chronic disease management What will
it take to improve care for chronic illness?
Effective Clinical Practice. 199812-4.
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Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
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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.
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
31
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.
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
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How would I recognize a productive interaction?
Prepared Practice Team
Informed, Activated Patient
Productive Interactions

• 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.

The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
33
The Care Model
Wagner EH. Chronic disease management What will
it take to improve care for chronic illness?
Effective Clinical Practice. 199812-4.
34
Summary

• Gerald L. Ignace Indian Health Center
• The current practice of Medicine
• IHS Directors initiative
• Care Model
• An example of change at our clinic

35
?
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• Planned Care Concepts
• Patient focused care
• Panels of patients
• Care team
• Huddle
• Staff work at the top end of their expertise
• Patient self-management

• Tools we use
• 80/20
• Process mapping
• Model for Improvement

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Prescription refills

• An Example of
• Process mapping and redesign at the Gerald L.
  Ignace Indian Health Center

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What do they mean
Decision Points
Start of a process
End of a Process
Activity Step
Waits or Delay
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Old Process
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(No Transcript)
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Model for Improvement
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
42
The PDSA Cycle for Learning and Improvement
Act
Plan
Objective Questions and predictions (why) Plan
to carry out the cycle (who, what, where, when)
What changes are to be made? Next cycle?
Study
Do
Complete the analysis of the data Compare
data to predictions Summarize what was learned
Carry out the plan Document problems and
unexpected observations Begin analysis of the
data
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
43
Model for Improvement
Changes That Result in Improvement in Practice
DATA and Learning
Implementation of adapted guideline(Large cost
of failure)
Wide-scale tests of adaptations
Clinical Research or Guidelines
Adaptation and follow-up Tests
The Improving Chronic Illness Care program is
supported by The Robert Wood Johnson Foundation,
with direction and technical assistance provided
by Group Health's MacColl Institute for
Healthcare Innovation
Very small scale test (Small Cost of failure)
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New Process
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EXCEPTIONS Elders Homeless Controlled Substances
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Yearly cost of prescription refills(Old Process)
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Yearly cost of prescription refills(New Process)
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Old Process vs. New Process

• Saves 5,182.00
• Translates to 235 nursing hours (0.1 FTE) a year
• Almost an hour a day saved

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EXCEPTIONS Elders Homeless Controlled Substances
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Thank you