Chronic Illness Care A framework for change

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Chronic Illness Care A framework for change

• Malcolm Battersby
• Associate Professor in Psychiatry
• Flinders University
• Flinders Human Behaviour and Health Research Unit

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Acknowledgements

• Mary, Ailish and Eve
• My Mentors Dr Ed Wagner and Michael Von Korff at
  Group Health in Seattle
• Commonwealth Fund of New York
• Oh and of course Mum and Dad

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Angels Landing at Zion
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Fellowship Activities in the United States

• Structured literature review of evidence base for
  self-management support
• Site surveys of mental health and Native American
  self-management programs
• Participation in 5 Break Through Series
  Collaboratives across the US
• Training in Lorigs Chronic Disease
  Self-Management Program - Stanford

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Downtown from Queen Anne
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Why do we need to change?

• Chronic disease has overtaken infectious disease
  as the main cause of mortality and morbidity
• Aging population
• Increase in chronic disease eg type 2 Diabetes
• Current system of care is based on an acute model

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Acute Chronic

• Ongoing-
• Stigma attached
• QOL highly dependent on pts self management and
  decision making
• QOL highly dependent on ongoing support services
• Pt often has more knowledge
• Short term goals to meet long term outcomes
• Compliance and self reliance expected

• Episodic
• Cure expected
• QOL highly dependent on professional care
• QOL highly dependent on short term services
• HP generally the expert
• Short term goals
• Compliance expected

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Sub-optimal PoorCare Outcomes

• Delays in detection of complications or decline
• Failures in self-management, or increased risk
  factors as a result of client passivity or
  ignorance.
• Reduced quality of care
• Undetected or inadequately managed psychological
  distress
• Wagner, E., Von Korff, M., et al, Organising Care
  for Patients with Chronic Illness. The Milbank
  Quarterly, Vol. 74, No.4, 1996

• Irregularor incompleteor inadequate .or
  inconsistent assessment,
• treatment
• education, motivation, feedback and /or
  follow up.

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Poor outcomes because.

• Poor compliance with medical management by
  patients (50)
• Poor adherence to behavioural lifestyle changes
  by patients (30)
• Combined with
• Poor adherence/compliance by clinicians with
  evidence based medicine and
• Poor self-management support by clinicians and
• Poor practice organisation of care

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Why is Chronic care important?(after McLellan et
al JAMA 243 1689, (2000).
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The US Health System

• A disorganised, expensive, inequitable mess
• And
• 43 million Americans are uninsured
• Health accounts for 15 of GDP cf 8-9 in OECD
  countries
• Despite this or because of it, there is a sense
  that something needs to be done urgently to
  improve quality of care and they are doing
  something about it

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US Health System

• Some exemplary services
• Government Veteran Affairs, Medicare, Medicaid,
  Indian Health Service
• Private, Health Maintenance Organisations Kaiser
  Permanente, Group Health
• States Indiana, Washington, New York, California

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Institute of Medicine Crossing the Quality Chasm
1996 - 2004

• the burden of harm conveyed by the collective
  impact of all of our health care quality problems
  is staggering (Chassen et al., 1998).
• There is a chasm (not a gap) between what we
  know to be good quality care and what actually
  exists in practice

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Harkness (US) Findings

• Institute for Health care Improvement (IHI)
• People receive recommended levels of care only
  50 of the time
• Significant health improvement will come about
  only through a social movement
• International Priorities
• Quality improvement reduce errors
• Redesign systems from acute to chronic illness
  care

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Evidence for What Works in Chronic Illness
Management

• The Chronic Care Model (CCM) Wagner et al
  Center for Health Studies, Group Health, Seattle
• 6 elements for achieving best outcomes for
  individuals and populations
• The primary outcome is an activated patient

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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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Evidence Base for Chronic Care Model (Wagner et
al 1996)

• Evidence from clinical trials of specific
  practice interventions (case managers,
  guidelines, reminders)
• Systematic reviews (hundreds of studies) by
  Cochrane Effective Practice and Organisation of
  Care group suggests a synergistic effect when
  multiple interventions are combined, eg
• Renders et al 2001, (diabetes)
• Rich et al, 1999 (congest cardiac failure)

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Chronic Care Model

• 1. Health System
• Leadership support for improvement
• Aligned incentives
• Care coordination across organisations
• 2. Community
• Encourage patients to participate in effective
  community programs
• Form partnerships with community organisations to
  fill gaps in services

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Practice Components of CCM

• 3.Self-management support
• Emphasise patients central role in managing
  his/her illness
• Assess patients self-management knowledge,
  behaviours, confidence and barriers
• Provide effective behaviour change interventions
  and on going peer or professional support

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Practice Components of CCM

• 4. Delivery System Design
• Defines roles and delegate tasks among team
  members
• Organise practice around planned care
• Provide case management for complex patients
• Ensure regular follow-up

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Practice Components of CCM

• 5. Decision support
• Incorporate evidence based guidelines into
  routine care
• Integrate specialist expertise into primary care
• Use proven provider education methods
• Share evidence based guidelines with patients and
  carers

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Practice Components of CCM

• 6. Clinical information system
• Provide reminders for patients and providers
• Identify sub populations for proactive care
• Monitor performance of practitioner, practice and
  care system

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Chronic Care Model Examples

• 1. Health System
• Leadership support for improvement
• Leader incorporates quality into business plan
  and vision
• Leader effectively communicates quality
  improvement culture
• Promote multidisciplinary teamwork
• Aligned incentives
• Use performance indicators to reward teams
• Care planning item numbers
• Care coordination across organisations
• Develop agreements with other organisations
• Primary Care Partnerships

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Chronic Care Model Examples

• 2. Community
• Encourage patients to participate in effective
  community programs
• Create a resource guide
• Delegate staff member to be community expert
• Identify evidence based community education
• Form partnerships with community organisations to
  fill gaps in services
• Invite community organisations to participate in
  redesign of care
• Use lay workers to link patients with community
• Co sponsor an exercise program with a health club

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Practice Components of CCM

• 3.Self-management support
• Emphasise patients central role in managing
  his/her illness
• Ask patients role in managing their health what
  do you think?
• Assess patients self-management knowledge,
  behaviours, confidence and barriers
• Use assessment tools eg Partners in Health
• Cultural competency training for staff
• Provide effective behaviour change interventions
  and on going peer or professional support
• Motivational interviewing, goal setting and
  problem solving

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Practice Components of CCM

• 4. Delivery System Design
• Defines roles and delegate tasks among team
  members
• Determine business process for planned care eg
  chronic care stream and care planning then
  delegate tasks
• Use protocols for planned care roles
• Organise practice around planned care
• Use a registry to proactively contact patients
  for follow up
• Provide case management for complex patients
• Develop patient selection criteria
• Nurse contact selected patients re
  self-management
• Ensure regular follow-up

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Practice Components of CCM

• 5. Decision support
• Incorporate evidence based guidelines into
  routine care
• Use locally adapted guidelines with prompts
• Integrate specialist expertise into primary care
• Create an agreed care plan, web based
• Use proven provider education methods
• Teach Problem and Goal setting, motivational
  interviewing
• Regular case conferences
• Academic detailing
• Share evidence based guidelines with patients and
  carers
• Provide care plan, shared decision making CDs eg
  prostate cancer

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Practice Components of CCM

• 6. Clinical information system
• Provide reminders for patients and providers
• Data base which has information to prompt
  guideline based care eg HbA1c
• Identify sub populations for proactive care
• Define criteria for sub populations identify
  nurse to routinely review data based and organise
  care
• Monitor performance of practitioner, practice and
  care system
• Use registry to determine percent of patients
  that have not had HbA1c in last 6 months eg
  Congress
• Audit the next 20 patients with a given diagnosis

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Evidence for Self-Management

• Von Korff et al 400 papers, reviews,
  meta-analyses
• Warsi et al, Archives Int Med, Aug 2004,
  diabetes and asthma
• Skill based education (knowledge alone is not
  sufficient)
• Collaborative problem definition
• Negotiated goal setting
• Organised follow-up

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Evidence-Based Principles for Self-Management
Support (SMS) in Primary Care

• Battersby et al 47 reviews and meta-analyses
• 12 Principles
• Multi-faceted interventions are more effective
• Assessment should guide interventions
• Skill enhancement benefits patients
• Counseling should be non-judgmental
• Goal setting problem solving are effective

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Evidence-Based Principles for Self-Management
Support (SMS)

• Interventions should strengthen self-efficacy
• Case management should be goal-directed
  evidence-based
• Registries planned follow-up are effective
  tools
• Diverse providers and formats can be effectively
  employed

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Collaboratives

• How to translate research into practice (beyond
  the project)
• Up to 25 teams meet on 4 occasions over 12
  months,
• 1-2 day learning sessions
• The Collaborative has clearly stated 12 month,
  clinical and process outcome goals
• Teams aim to implement the 6 elements of the CCM

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Chronic Care Collaboratives

• 3 different content (disease/condition) areas to
  20 or more participating organisations
• An improvement method
• The Chronic Care Model
• Condition specific content
• Use the Assessment of Chronic Illness Care tool
  (ACIC) tool to rate improvement of the 6 elements
  of the chronic care model

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Collaboratives

• The core process for the teams is the
• Plan Do Study Act (PDSA) cycle
• The Team include non clinicians, innovators
• Set short term 8 day goals
• Have faculty follow up/support

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Collaborative Requirements

• Accountability
• Creativity
• Reward and recognition
• High level leadership support
• Measurement registry data base to create a
  population focus based on individual patient
  measures

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Controlled Study

• Breakthrough Collaborative Series
• Robert Wood Johnson Foundation 1998, 25
  million
• Improving Chronic Illness Care
• Inst for Healthcare Improvement (IHI) and McColl
  Institute (Wagner et al)
• Use Collaboratives to promote adoption of Chronic
  Care Model with a focus on
• Diabetes
• Heart failure
• Asthma
• Depression

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Rand Evaluation of Improving Chronic Illness Care

• http//www.rand.org/health/projects/icice/findings
  .html
• Emmett Keeler chief evaluator
• 36 sites
• Design Comparison group with usual care
  evaluating processes, outcomes and costs over 12
  months
• 700 staff, 2,200 intervention and 1,800 controls

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Rand Evaluation

• Organisations made an average of 48 changes in
  line with the CCM
• 81 of organisations made changes in all 6 CCM
  elements
• 1 year after the changes were introduced, 82 had
  sustained the changes and 79 had spread their
  changes to other areas

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Clinical outcomes

• Diabetes patients reduced heart disease risk
  factors from 3.2 to 2.8 compared to no change
  in control group
• Eye exam increased 19 in intervention and 13 in
  controls cf with 2 nationally
• Asthma patients had increased monitoring of peak
  flows and had a written action plan
• Asthma no difference in use of long term
  controller medications

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Clinical Outcomes

• Heart failure improved self-management incl
  knowledge and self-management skills
• 86 of intervention patients reported education
  re daily weighing cf 34 in control group
• No difference in quality of life
• Increased satisfaction with doctor by
  intervention patients

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Rand Evaluation

• Costs 35,000 to participate
• 100,000 for implementation
• Re-hospitalisation costs not assessed because of
  small no of patients, short time frame, not a
  high risk sample

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Collaboratives Success Elements

• Teams that met weekly
• Successful teams averaged 45 changes
• Successful teams had a high number of early
  change cycles
• A culture of teamwork and growth
• Not dependent on baseline features of CCM
• Not dependent on wealth of the organisation

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Collaboratives Success Elements

• Teams with a higher proportion of doctors
• Teams with a team champion
• High organisational commitment to quality
  improvement
• Contact with other teams during the collaborative
• Emphasis on collaborative decision making with
  patients

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Which Elements of the CCM?

• Not enough sites to test this but
• Meta analysis of 112 published studies found that
  each element produced improved outcomes but no
  single element was found to be either essential
  or superfluous.

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Indian Health Service

• National Diabetes Program
• National standards, service accreditation
• Self-management education modules
• Diabetes educators
• National registry data base
• 5 year improvement in HbA1c

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Indiana Chronic Disease program

• Target group Medicaide patients low income
  individuals and families (4500 people)
• The Model
• Call centre
• Case managers
• A registry
• The Collaborative

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Indiana Outcome targets

• Diabetes and cardiac At 12 months
• 80 of all diabetic patients to have a HbA1c test
  in the last 12 months
• 30 of all diabetic patients to have HbA1c lt7 by
  12 months
• 60 of all cardiac patients to have
  self-management goals documented

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Registry

• A data base provided to all clinics for each
  doctors patients involved in the collaborative
• Provides all pathology results from the last 12
  months
• Evidence based recommended services for each
  condition diabetes, heart disease eg podiatry,
  HbA1c, ophthalmology etc
• Recall and reminder system for clinic staff and
  patient
• Provides above information on each patient and
  able to provide report for all clinic patients
  with same characteristics eg diabetes with HbA1c
  gt10

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Indiana

• Registry (cont)
• Able to collect names of patients to organise
  group education, eg disease specific, lifestyle
  etc
• Able to provide aggregated data on all patients
  involved in the collaborative

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Call Centre

• Care coordinators using a software program linked
  to the medicaide data base with each patients
  health status and care planning self-management
  goals
• Care coordinators have health related
  qualification, not necessarily a clinician
• Chosen for their telephone ability not clinical
  competence

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Call Centre

• Initial assessments conducted by phone
• 15 allocated to case managers but still
  registered with the call centre
• Care coordinators followed stepwise algorithm for
  each planned call. a form of coaching based on
  the medical and self-management goals and risk
  factors

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Call Centre

• Screening questions eg depression with subsequent
  questions to determine severity and risk.
• Provide education materials and local programs
• Summary emailed to GP with agreed follow up
  actions
• Check back technique for patient satisfaction and
  understanding
• Back up of case manager/GP if required

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Case Managers

• Community health nurses
• Patients pre selected based on the most complex
  10 with high service use
• Home visits full assessment of medical, social
  and psychological needs
• Time limited 6 months
• Communication with GP

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Results

• 60-80 improvement in all measures at 12 months

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Take home lessons from Fellowship Year

• There is evidence that chronic care can be
  implemented in diverse practices and teams using
  a collaborative approach
• Government Policy
• Set priorities in chronic/preventive care,
• Set population targets for health gain and
• Direct new resources from acute care to evidence
  based chronic care prevention and management

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Only in Australia
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And lastOnly In America
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Information

• http//www.improvingchroniccare.org
•  
• http//www.indianacdmprogram.com
• www.ihi.org

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Thank You

• Flinders Human Behaviour and Health Research Unit
• Malcolm.Battersby_at_flinders.edu.au
• Ph [phone] Fax [phone]
• http//som.flinders.edu.au/FUSA/CCTU/Home.html