Redesigning Care to Meet the Needs of the Chronically Ill Patient

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Redesigning Care to Meet the Needs of the
Chronically Ill Patient

• Mike Hindmarsh
• Improving Chronic Illness Care,
• a national program of the Robert Wood Johnson
  Foundation

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Improving Chronic Illness CareA national program
of the Robert Wood Johnson Foundation
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Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
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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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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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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

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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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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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Features of case management

• Regularly assess disease control, adherence, and
  self-management status
• Either adjust treatment or communicate need to
  primary care immediately
• Provide self-management support
• Provide more intense follow-up
• Provide navigation through the health care
  process

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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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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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Early research findings about The Care Model
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RAND Evaluation questions

• Do organizations in a Collaborative change their
  systems for delivering chronic illness care?
• Does implementing the Chronic Care Model improve
  processes of care and patient health
• http//www.rand.org/health/ICICE

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RAND Findings Comparing Collaborative Participant
Patients with Controls

• Decreases in HbA1c for patients with diabetes
• Significant increase in patient reports of
  counseling, education and improved lifestyle for
  CHF
• Significant improvement in QOL for patients with
  asthma
• Significant increase in patients on controller
  medications

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Health system experiences
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A Recipe for Improving Outcomes
System change strategy

• Learning
• Model

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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 1000 health care systems involved to date
• Both national and regional collaboratives
• Collaboratives frailty in the elderly,
  diabetes, CHF, asthma, depression, arthritis,
  AIDS, CVD, prevention

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Regional Collaboratives (past present)

• Washington State Diabetes I, II, III
• Alaska Diabetes
• Oregon Diabetes, CHF
• Chicago Diabetes
• Vermont Diabetes I, II
• New Mexico Diabetes
• Wisconsin Diabetes I, II
• Arkansas Diabetes
• Nevada Diabetes

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Regional Collaboratives (contd)

• Maine Diabetes
• Rhode Island Diabetes
• Arizona Diabetes
• North Carolina Diabetes
• New York Asthma and Prenatal Care
• Indiana Chronic Disease Management Program
• New York Health and Hospital Diabetes CHF

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Successes of Teams in Collaboratives The
Benefit of Organized Chronic Care

• 1.5 - 2 times as many patients with major
  depression will be recovered at six months
• Inner city kids with moderate to severe asthma
  have 13 fewer days per year with symptoms
• Readmission rates of patients hospitalized with
  CHF will be cut nearly in half

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Performance of 26 Delivery Systems in WA
Diabetes II Collaborative
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Premier Health Partners

• Dayton, Ohio
• 100 physicians in 36 practices
• Change began in one practicespread throughout
  system
• ACE-inhibitors for albuminuria was 38 in 1999
  and 80 in 2001
• A1c lt 7 was 42 in 1999 and 70 in 2001

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Disease Management Vendors

• Typically single disease carve-out model
• Some shift towards carve-in
• Segmentation of high risk
• No RCT evidence of clinical or cost effectiveness
• No effort to build capacity of primary care

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Questions to Ask DM Vendors

• Carve-in or out?
• How much risk?
• Interventions for whole population?
• Linkage to primary care providers?
• Details of intervention (especially CM)?
• Handling of co-morbidities?

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What is Involved in a State Approach?

• Creating systemness on a regional level
• Strong coalition of stakeholders
• IT infrastructure
• Ability to reach practices through data and
  incentives
• Clinical support via guidelines, case management,
  self-management support training
• QI training and tools
• Performance monitoring and feedback
• Technical assistance for all practice types

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• www.improvingchroniccare.org

Thank you