CHIC The Chronic Care Model

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CHICThe Chronic Care Model

• Robert C. Block, MD, MPH, FACP
• Department of Community and Preventive Medicine

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Personal Commentary

• Internal medicine practice with focus on
  preventive cardiology
• Complexities and challenges of caring for those
  with chronic disease
• Importance of population health-limits to
  improving health via one-on-one encounters
• Public health training

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Case 1

• 75 year old white female with HTN,
  hyperlipidemia, type 2 diabetes, and chronic
  renal insufficiency.
• BP 150/92
• HgbA1C 9.0
• LDL 130, HDL 33, triglycerides 200
• Estimated creatinine clearance 30 mL/min

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Case 1

• Clinical care disjointed, seeing a different
  provider for office visits
• Cardiovascular disease risk factors not well
  controlled
• She has an inferior wall MI with hypotension,
  cardiac arrest, is resuscitated and has anoxic
  encephalopathy.
• No living will/health care proxy
• What do we do now?

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The Tyranny of the Urgent

• We need to manage her acute illness and hopefully
  her chronic issues better next time
• Why-we were trained to care for those with acute
  illness and all the care is reimbursed
• Is this the correct paradigm?
• Is this the least expensive and most
  patient-centered outcome?

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The Tyranny of the Urgent

• Current system prioritizes treatment of acute
  illness
• Examples include MI, CHF, acute renal failure,
  asthma, diabetic ketoacidosis, pneumonia.
• Each can either be prevented in the majority of
  circumstances and some are amenable to outpatient
  therapy.
• What is most important Savvy diagnostics and
  treatment or excellent (sometimes tedious)
  management of chronic issues?
• Bodenheimer T, Wagner E.H., Grumbach, K.
  Improving primary care for patients with chronic
  illness. JAMA. 20022881775-1779.

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Case 2

• 45 year old African-American male with sickle
  cell disease and subsequent chronic renal
  failure/transplant
• Recently unemployed
• Without health insurance
• Develops pneumococcal sepsis-disaster
• How can we return him to optimal health?

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The Chronic Care Model

• A guide to high quality chronic illness
  management within primary care.
• Components
• Community resources and policies
• Health care organization
• Self-management support
• Delivery system design
• Decision support
• Clinical information systems

Wagner EH, Austin BT, VonKorff M. Organizing care
for patients with chronic illness. Milbank
Quarterly. 199674(4)511-542
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Community Resources and Policies

• What CHIC has normally focused on.
• Public health agencies such as Monroe County
  Health Dept, American Heart Association, etc.
• Can provide for network of services including
  prevention programs, vaccinations, case managers.
• Educational programs

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Community Resources and Policies

• For this patient, visiting nurse services will be
  a benefit for a period of days to weeks.
• He may require transportation assistance,
  medication assistance right away.
• Community resources will assist those with acute
  and chronic disease
• Important safety net/resource

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Health Care Organization

• How does the medical organization prioritize
  resources?
• For acute care?
• For chronic care?
• What is its relationship to other components of
  the model?
• For this patient, will the comprehensive care he
  requires be provided?

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Health Care Organization

• If chronic care were a priority, vaccination
  status should have been addressed systematically
  and not forgotten in the midst of acute issues
  and fragmented care.
• A pneumovax might have prevented sepsis
• Enhanced preventive services might improve
  organizations standing with insurers and rates
  of reimbursement-profit for organization!

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Delivery System Redesign

• How is the system designed? A system is
• an organized or established procedure or a
  harmonious arrangement or pattern.
• Is it a real system or simply ad hoc?
• Does it empower all health care workers to their
  full potential?
• Are formal disease management strategies present?
• Why should we reinvent the wheel?

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Delivery System Redesign

• New models challenge the culture of medicine
• Chronic disease management protocols, teams, can
  be an integral part of effective practices
• Proactive vs. reactive
• Comprehensive rather than piece-meal

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Delivery System Redesign

• Wasson, et al, showed that substituting regularly
  scheduled follow-up phone calls for irregular
  follow-up visits improved health status and
  reduced costs for chronically ill patients.
• Telephone-care patients had less medication use
  (14, P .006), fewer admissions, and shorter
  stays in the hospital (28 fewer total hospital
  days, P .005), and 41 fewer intensive care
  unit days (P .03).

Wasson JC, Gaudette C, Whaley A, et al. Telephone
care as a substitute for routine clinic
follow-up. JAMA.19922671828-9.
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Delivery System Redesign

• For the subgroup of patients with fair or poor
  overall health at the beginning of the study (n
  180), savings were somewhat greater (1,976, P
  .01). In this subgroup, improvement in physical
  function from baseline (P .02) and a possible
  reduction in mortality (P .06) were also
  observed.
• We conclude that substituting telephone care for
  selected clinic visits significantly reduces
  utilization of medical services. For more
  severely ill patients, the increased contact made
  possible by telephone care may also improve
  health status and reduce mortality.

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Delivery System Redesign

• A care-management system incorporating nurses,
  other allied staff, with vaccination protocols,
  could have provided the vaccine without a
  physicians order.
• A nurse manager can coordinate care once he
  leaves the hospital.
• A social worker can help provide home resources,
  financial support, medication assistance.

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Decision Support

• Can physicians remain current with all expert
  recommendations? No.
• Do all physicians become tired, stressed, rushed?
  Yes.
• Do physicians make mistakes? Yes.
• Why not make helping them a priority?
• Example is the airline industry and subsequent
  focus on reducing medical errors.

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Decision Support

• How can such support help this patient?
• Vaccinations
• Management of complex chronic illnesses
• Addressing all issues such as depression which
  can develop after a life-threatening illness
• Actively managing issues in primary care is less
  expensive and more convenient, cohesive for
  patients than scattered care.

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Decision Support

• Can add sophistication to cookbook and harried
  care.
• Guidelines are currently not adhered to for many
  conditions including HTN, hyperlipidemia, smoking
  cessation counseling.
• Team-based care.

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Decision Support

• Patient registries can help organize care
• Reminder systems can assist providers in
  addressing all issues
• The use of reminder systems and registries to
  maintain surveillance of hypertensive patients
  has been repeatedly shown to improve the care of
  those with high blood pressure.

Wagner EH, Austin BT, VonKorff M. Organizing care
for patients with chronic illness. Milbank
Quarterly. 199674(4)511-542
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Clinical Information Systems

• Computerized medical records can serve 3
  purposes
• Reminder systems to assist compliance with
  clinical guidelines
• Providing feedback to physicians on the quality
  of their care
• As registries for planning individual care and
  conducting population-based care

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Clinical Information Systems

• An electronic medical record (EMR) should help
  the physician to provide better care.
• It should help coordinate care in outpt, inpt
  settings, and nursing homes.
• It might even provide patients access to their
  own medical record, appointments, links to
  educational tools.

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Clinical Information Systems

• A good EMR will provide access to all medical
  records from acute illness, nephrology,
  transplant clinic, hematology seamlessly.
• Vaccine status can be checked easily as well as
  medications, testing, follow-up appointments.

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Public Health Relevance

• So what? Why educate you about the Chronic Care
  Model during CHIC?
• Why make the Chronic Care Model the focus of some
  of your projects?
• Why might those of you who are planning to become
  subspecialists benefit from experience with
  components of the model?

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Public Health Relevance

• Extremely relevant as chronic disease is a huge
  public health burden in the US
• Improved chronic disease care will bolster the
  health of the community
• A true system of care requires community
  partnerships and innovations
• Primary care and specialty care providers will
  all treat those with chronic disease
• Model may also be applied to acute care

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Public Health Relevance

• Whether you realize it or not, as a physician you
  already influence public health
• You are not only involved in patient care, you
  are also part of larger systems that are working
  to integrate care and resources
• Thinking outside of the box is something that
  practicing physicians have not been known for
• Improving care processes can be very rewarding

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Public Health Relevance

• So what? Why educate you about the Chronic Care
  Model?
• Endorsers include
• American College of Physicians (Optimal Medical
  Home), Robert Wood Johnson Foundation (funded
  Improving Chronic Illness Care study by RAND
  Corporation), the Institute for Healthcare
  Improvement, American Academy of Family
  Physicians

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Project Examples

• Help a local doctors office develop a process
  for reminding providers to counsel patients to
  quit smoking
• Help a local doctors office to provide emergency
  departments with pertinent information to help
  them triage/evaluate referred patients
• Act as a liaison between the American Heart
  Association and cardiac rehab centers in order to
  improve educational literature for patients and,
  perhaps, to develop better literature or websites

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Project Examples

• Help organize a group of physicians and hospitals
  to lobby the NY State Legislature to develop a
  universal health insurance bill, in association
  with the American College of Physicians
• Help the American College of Physicians to pilot
  a project implementing the Advanced Medical Home
  (Chronic Care Model) in Rochester