Adult Chronic Care Model

1
Adult Chronic Care Model

• Robert Kushner, MD
• Northwestern University
• Feinberg School of Medicine
• Chicago, IL

2
Yach D, et al. JAMA 20042912616-22
3
Global Mortality From Chronic Diseases
Yach, D. et al. JAMA 20042912616-2622.
4
The Impact of LifestyleA Global Perspective

• Globally, noncommunicable or chronic diseases
  currently account for about 60 of all deaths and
  47 of the global burden of disease. These
  figures are expected to rise to 73 and 60,
  respectively, by 2020 (WHO 2002).

5
The Impact of LifestyleA Global Perspective

• A WHO report titled Global Strategy on Diet,
  Physical Activity and Health notes that routine
  contacts with health-service staff should include
  practical advice to patients and families on the
  benefits of healthy diets and increased levels of
  physical activity, combined with support to help
  patients initiate and maintain healthy behaviors
  (WHO 2004).

6
Is the Current System Set up for Management of
Chronic Disease?
7
Bringing state-of-the-art care to all Americans
in every community will require a fundamental,
sweeping redesign of the entire health
care system
8
(No Transcript)
9
Priority Areas for National Action Transforming
Health Care Quality Karen Adams and Janet M.
Corrigan, Editors Committee on Identifying
Priority Areas for Quality Improvement Board on
Health Care Services INSTITUTE OF MEDICINE OF
THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES
PRESS 2003
The committee considered quality to be a systems
property, recognizing that although the health
care workforce is trying hard to deliver the
best care, those efforts are doomed to failure
with todays outmoded and poorly designed
systems.
10
Developing a Chronic Care Model (CCM) of Care (A
Systems Approach)

• Put Prevention Into Practice
• AHRQ
• www.ahrq.gov
• Improving Chronic Illness Care
• http//improvingchroniccare.org
• Chronic care training manual
• ICIC Improving your practice manual
• Tools

11
(No Transcript)
12
Themes of Chronic Care Model

• Evidence-based - care delivered according to
  proven clinical pathways and health services
  interventions
• Population-based - focus on assuring needed care
  to all members of a population rather than simply
  individual patients (e.g., use of registries)
• Patient-centered - high priority given to
  patients participation, confidence skills in
  managing illness

13
Chronic Care Model (CCM)
2. Health System
1.Community
Health Care Organization
Resources and Policies
6. ClinicalInformationSystems
4. DeliverySystem Design
3. Self-Management Support
5. Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
ICIC
14
2. Health System
1.Community
Organization of Health Care Leadership concerned
about the bottom line Incentives favor more
frequent, shorter visits No organized QI
Resources and Policies No links with
community agencies or resources
6. ClinicalInformationSystems Dont know pts or
what they need
4. DeliverySystem Design Reliance on short,
unplanned visits
5. Decision Support No agreement on good care
traditional referrals
3. Self-Management Support No systematic
approach didactic in orientation
Frustrating Problem-Centered Interactions
Uninformed, Passive Patient
Unprepared Practice Team
Suboptimal Functional and Clinical Outcomes
ICIC
15
Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
ICIC
16
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
ICIC
17
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!
ICIC
18
Prescription for Health (P4H)

• P4H Promoting Healthy Behaviors in Primary Care
  Practice-Based Research Networks (PBRN)
• RWJF and AHRQ initiative
• Funded 17 practices (2 adolescent, 2 children) in
  Round 1 July, 2003 to October, 2004
• 4 health risk behaviors
• Inactivity, poor diet, tobacco use, alcohol

Ann Fam Med 20053(Suppl 2)
19
(No Transcript)
20
1. Community Linkages

• Current state
• Support structures key community resources
  not linked to health care
• What change is needed?
• 1. Formal partnerships coalitions formed
  with community centers to ensure continuity in
  care
• 2. Formal referral system to community
  centers

ICIC
21
Community Resources

• School boards
• Park authorities
• Workplaces
• Churches
• Bars
• Restaurants
• Theaters
• Urban planners

• Sports centers
• Grocers
• Retail outlets
• Volunteer organizations
• Senior centers
• News media
• advertisers

Woolf SH, et al. Ann Fam Med 20053(Suppl
2)S20-S27
22
Conmmunity is Critical Source of Care and Support
23
(No Transcript)
24
P4HCommunity Resources

• Locally based community health advisors
• Web-based directions of community resources
• Web links to relevant information or resources
  outside community (regional or national)

Cifuentes DH, et al. Ann Fam Med 20053(Suppl
2)S4-S12
25
2. Health System Organization

• Current state
• Leadership, incentives QI approaches are
  directed at ensuring the bottom line
• What change is needed?
• 1. Goals for chronic illness care in
  strategic plans
• 2. Senior leader support
• 3. Generate QI projects with likelihood of
  success
• 4. Incentives benefits support good care

ICIC
26
P4HHealth care organization

• Practice-wide assessments
• Clinician assessments (attitudes, satisfaction,
  readiness to change)
• Evaluation of use of specific tools or techniques
• Negotiated support from insurers for project
  activities

Cifuentes DH, et al. Ann Fam Med 20053(Suppl
2)S4-S12
27
3. Self Management Support

• Current state
• Self management programs not well integrated
  in clinical care
• What is needed?
• 1. Standardized assessment of patient needs
• 2. Emphasis on patients role in managing
  illness
• 3. Patient access to safe effective
  behavioral change programs

ICIC
28
Self-Management Support

• Give information
• Teach disease-specific skills
• Negotiate healthy behavior change
• Provide training in problem-solving skills
• Assist with the emotional impact of having a
  chronic condition
• Provide regular and sustained follow-up
• Encourage active participation in the management
  of the disease

Bodenheimer T. JAMA 20072982048
29
P4HSelf-management support

• Patient-centered goal setting and action plans
• Motivational interviewing techniques
• Physical activity and dietary logs
• Community resource directories
• Local walking club
• Periodic follow-up from health change
  facilitators, educators, or advisors
• Telephone and email follow-up and support
• pedometers

Cifuentes DH, et al. Ann Fam Med 20053(Suppl
2)S4-S12
30
4. Delivery System Design

• Current state
• Provider roles are unclear focus of visits
  is on acute flare ups follow up is suboptimal
• What is needed?
• 1. Clearly define roles tasks
• 2. Schedule planned, preventive visits
• 3. Ensure continuity and follow-up

ICIC
31
P4HDelivery system design

• Patient questionnaires before visit and ongoing
  (web-based)
• Staff role changes and education
• Health advisors, educators, coaches/health change
  facilitators
• Brief interventions
• Periodic health assessments (vital signs)
• Prescription pads for health behaviors
• Group visits
• Telephone and email follow-up support

Cifuentes DH, et al. Ann Fam Med 20053(Suppl
2)S4-S12
32
5. Decision Support

• Current state
• Usual practice deprives patients of proven
  treatments we think patients dont get
  guidelines
• What change is needed?
• 1. Increase specialist involvement in
  primary care, e.g, obesity care teamlet model
• 2. Develop clear guidelines for care
  decisions
• 3. Implement provider education programs
• 4. Share guidelines with patients

ICIC
33
P4HDecision support

• Patient-reported health behavior information
• Relevant preventive services guidelines
• Patient readiness to change assessment
• Streamlined evidence-based assessment and
  screening tools
• Tailored scripts and techniques
• Patient-tailored care recommendations
• Electronic (web, PDA) decision-support tools
• E.g., Lifestyle Medicine patient care handouts

Cifuentes DH, et al. Ann Fam Med 20053(Suppl
2)S4-S12
34
6. Clinical Information Systems

• Current state
• Registries limited patients fall through
  the cracks providers lack info to prevent
  complications and optimize disease control.
• What is needed?
• 1. Registries that track important outcomes
  have built in provider reminder systems
• 2. Relevant subgroups of patients (e.g., at
  risk) can be identified through registry.

ICIC
35
Clinical Information System Registry

• A registry includes clinically useful and timely
  information on all patients.
• Information system provides reminders and
  feedback for providers and patients.
• Registry can identify relevant patient subgroups
  for proactive care.
• Registry facilitates individual patient care
  planning.

ICIC
36
P4HClinical information systems

• Reminder systems (electronic, posters,
  assessments, patient-reported behavior
  indicators)
• Patient-completed screening tools
• Logs and behavioral questionnaires
• Expanded vital signs to include risky health
  behaviors

Cifuentes DH, et al. Ann Fam Med 20053(Suppl
2)S4-S12
37
3 steps to improve feasibility and sustainability
of PBRN research around health behavior
intervention
P4H Lessons Learned

• Research team members need a strong understanding
  of the organizational features of practice that
  have been shown to mediate successful
  implementation of practice change interventions.

Cohen DJ, et al. Ann Fam Med 20053(Suppl
2)S12-S19
38
3 steps to improve feasibility and sustainability
of PBRN research around health behavior
intervention
P4H Lessons Learned

• Need to develop collaborative multidisciplinary
  teams that bring together experts in such areas
  as information technology, patient care and
  counseling, community outreach, clinician
  education, and practice organization and change.

Cohen DJ, et al. Ann Fam Med 20053(Suppl
2)S12-S19
39
3 steps to improve feasibility and sustainability
of PBRN research around health behavior
intervention
P4H Lessons Learned

• Reflect on their philosophy and approach for
  managing the research process. Take steps to
  motivate practices, to ease the burden a research
  project places on a practice, and develop
  organizational systems for managing multiple
  projects simultaneously.

Cohen DJ, et al. Ann Fam Med 20053(Suppl
2)S12-S19
40
Intervention used in disease management programs
for patients with chronic illness

• Asthma
• Back pain
• CAD
• Chronic pain
• CHF
• COPD

• ESRD
• Hyperlipidemia
• Hypertension
• Arthritis
• Depression
• Diabetes

Weingarten SR et al BMJ 2002325925
41
Impact of disease management on control (number
of positive trials)
Classification of Interventions

• Provider education 12/32 (37)
• Provider feedback 9/23 (39)
• Provider reminders 6/14 (43)

• Patient education 24/55 (44)
• Patient reminders 6/16 (37)
• Patient financial incentives 3/4 (75)

Weingarten SR et al BMJ 2002325925
42
Bodenheimer T. et al. JAMA 20022881909-1914
43
P4H Round 2

• Prescription for Health is working with 10 PBRNs
  to
• Develop effective, practical strategies for
  changing Americans' unhealthy behaviors through
  primary care
• Understand and measure the extent to which more
  comprehensive health behavior counseling
  strategies are effective in improving patients'
  behaviors and result in improved practice
• Evaluation outcomes using a common set of patient
  and practice measures, and assess the strategies
  for reach, effectiveness, adoption,
  implementation, and maintenance

44
P4HRound 2
In the second round of funding, 10 PBRNs were
awarded 24-month grants of 300,000 each. The
networks are implementing and evaluating the
proposed studies in 99 primary care practices.
The goal of this round is to understand and
measure the extent to which more comprehensive
strategies are effective in improving patients
health behaviors and result in improved
practice.
45
P4H Round 2
Examples of current projects include ?
PDA-based assessment of health risks for
adolescents with tailored in-office counseling,
and follow up through community referrals and
web-based resources ? Creation of new types of
staff positions, such as a community health
educator and referral liaison who will serve as a
bridge between the practice, patient, and
community in the form of a one-stop-shopping
health behavior referral service ? Interactive
voice response system used to conduct risk
assessment and deliver tailored counseling over
the phone ? Electronic health record prompts for
providers with different options for counseling
and follow up including web-based,
telephone-based, and group visits ? Reframing
the 2-year old well-child visit to focus on
family lifestyle risk assessment and behavior
change for the entire family through referrals to
lifestyle counselors
46
(No Transcript)
47
Looking Ahead

• 1) Professional/lay education. Will need to
  provide skill-oriented interactive training
  programs on self-management, behavioral change
  theories and methods, interdisciplinary care
  teamwork, and information systems.
• 2) Public policy/advocacy. The chronic care model
  will require reengineering of the health delivery
  system, including reimbursement issues,
  organization of health care, emphasis on
  prevention, and development of community
  resources.
• 3) Research. Quality improvement, health outcomes
  and health economics will need to be evaluated
  for delivery of obesity care with the chronic
  care model versus usual care.