Improving the Care of the Chronically Ill

1
Improving the Care of the Chronically Ill the
Advanced Medical Home
Ed Wagner, MD, MPH, FACP
MacColl Institute for Healthcare
Innovation Center for Health Studies Group Health
Cooperative Improving Chronic Illness Care A
national program of the Robert Wood Johnson
Foundation
2
Chronic Illness and Medical Care

• Primary care dominated by chronic illness care
• Clinical and behavioral management increasingly
  effective and increasingly complex
• Inadequate reimbursement and greater demand
  forcing primary care to increase throughputthe
  hamster wheel
• Unhappy primary care clinicians leaving practice
  trainees choosing other specialties
• Loss of confidence in primary care by
  policy-makers and funders
• But, there is a growing interest in changing
  physician payment to encourage and reward quality
• The Patient-centered Medical Home is the new hope

3
Why are we doing so poorly?

• The IOM Quality Chasm report says
• The current care systems cannot do the job.
• Trying harder will not work.
• Changing care systems will.

4
Whats Responsible for the Quality Chasm?

• A system oriented to acute disease that isnt
  working for patients or professionals

5
Toward a chronic care oriented system

• Reviews of interventions in multiple conditions
  show that practice changes are similar across
  conditions
• Integrated changes including greater use of
• non-physician team members in clinical roles
• planned encounters,
• modern self-management support,
• More intensive management of those at high risk
• guidelines integrated into decision-making
• registries

6
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
Outcomes
Improved Outcomes
7
Central Functions of a PCMH

• Assures communication access to team
• Monitors health and needs of practice population
  and initiates action
• Organized practice team meets to plan care and
  assure follow-up
• Provides care management or outreach services to
  those with higher needs
• Develops processes to assure care coordination
  with other providers
• Routinely monitors performance and uses process
  improvement

8
The Evidence Base
Does the CCM Work?
9
Organizing the Evidence

1. Randomized controlled trials (RCTs) of
   interventions to improve chronic care
2. Studies of the relationship between
   organizational characteristics and quality
   improvement
3. Evaluations of the use of the CCM in Quality
   Improvement
4. RCTs of CCM-based interventions
5. Cost-effectiveness studies

10
1 RCTs of interventions to improve chronic care
results

• Complex, integrated care, multi-component
  programs show most positive effects on quality of
  care
• Consistently powerful elements include team
  care, care management, self-management support,
  reminders and registries

11
2 Studies of the Relationship between
Organizational Characteristics and Quality

• Common organizational characteristics across
  studies
• Organized teams, including physicians, involved
  in quality improvement
• Patient registries and reminder systems
• Performance Reporting
• Formal self-management programs
• Others Characteristics associated with process
  improvement include
• Receiving income, recognition, or better
  contracts for quality
• Improved IT infrastructure
• Utilizing guidelines supported by academic
  detailing

12
3 Evaluations of the Use of CCM in Quality
Improvement

• Largest concentration of literature
• Includes RAND Evaluation of ICI
• Two evaluations of the Health Disparities
  Initiative
• Wide variety in quality and type of evaluation
  design
• Majority of studies focus on diabetes

13
3 RAND Evaluation of Chronic Care Collaboratives

• Two major evaluation questions1. Can busy
  practices implement the CCM?2. If so, would
  their patients benefit?
• Studied 51 organizations in four different
  collaboratives, 2132 BTS patients, 1837 controls
  with asthma , CHF, diabetes
• Controls generally from other practices in
  organization
• Data included patient and staff surveys, medical
  record reviews

14
3 RAND FindingsImplementation of the CCM

• Organizations made average of 48 changes in 5.8/6
  CCM areas
• One year later, over 75 of sites had sustained
  changes, and a similar number had spread to new
  sites or new conditions.

15
3 RAND Findings (2)Patient Impacts

• Diabetes pilot patients had significantly reduced
  CVD risk (pilot gt control), resulting in a
  reduced risk of one cardiovascular disease event
  for every 48 patients exposed.
• CHF pilot patients more knowledgeable and more
  often on recommended therapy, had 35 fewer
  hospital days and fewer ER visits
• Asthma and diabetes pilot patients more likely to
  receive appropriate therapy
• Asthma pilot patients had better QOL

16
3 Evaluations of the Health Disparities
Collaboratives
Chin et al. Landon
et al.

• Studies national group of CHCs
• Followed patients 1 year post-collaborative
• Only found process improvements

• Studied midwest CHCs
• Followed patients for 2-3 years
  post-collaborative
• At 1 year improvement in process LDL
• At 2-3 years improvement in process, LDL, and
  HBA1c

17
4 Randomized Controlled Trials (RCT) of
CCM-based Interventions

• 6 RCTs covering asthma, diabetes, bipolar
  disorder, comorbid depression and oncology, and
  multiple conditions
• 5 in the US disease specific, 1 in Australia
  multiple diseases
• Practice-level randomization
• 5 of 6 showed significant improvements in patient
  health

18
5 Cost Effectiveness Study Results

• Some evidence that improved disease control can
  reduce cost, especially for congestive heart
  failure, asthma (among populations with high ER
  and hospital use) and uncontrolled diabetes
• Huang et al. found that an HDC diabetic patient
  cost an additional 380/yr but increases QALY by
  4-5 months.

19
Medical home Chronic Care ModelDuplicative,
Complementary or Antagonistic?

• Both emphasize and support patient role in
  decision-making
• MH redefines primary care responsibility
• CCM redesigns care delivery for planned care

20
What are the key features of a PCMH?NCQA Measure
21
What are the key features of a PCMH? ACP, AAFP,
AAP, AOA joint statement

• Personal Physician 1st contact, continuous,
  comprehensive care
• Team Care collectively take responsibility for
  ongoing care
• Whole Person Orientation take responsibility
  for all patient needs by delivering or arranging
  care
• Coordinated Care across all elements of the
  healthcare system
• Quality and Safety by implementation of CCM,
  continuous QI, and voluntary recognition process
• Enhanced access via open scheduling, expanded
  hours and new options for communication
• Payment recognizes value of the PCMH, pays for
  coordination and electronic communication with
  patients, , supports IT use,

22
Commonwealth Fund Operational Definition of a
Patient-centered Medical Home

• One has a regular source of care
• And
• It is not difficult to contact the providerby
  telephone
• It is not difficult to get care or advice after
  hours
• Office visits are generally well organized and
  running on time

23
(No Transcript)
24
Commonwealth Survey of Americans 18-64 Whats
the impact of a MH on getting patient needs met?
Percent of adults always getting the care they
need when they need it.
25
Commonwealth Survey of Americans 18-64 Whats the
impact of a MH on getting preventive care
reminders?
receiving reminders to schedule preventive
visits
26
(No Transcript)
27
What are the barriers?

• The hamster wheel
• Limited practice infrastructure clinical staff
  and IT
• Practice isolation
• Belief in the quality of ones practice i.e. no
  meaningful measurement
• Belief that the doctor has to do
  everything(underdevelopment of practice team)
• Financial disincentives

28
Whats needed to improve chronic illness care for
the population?

• Leadership
• Standardized measurement
• Redesigned physician payment including incentives
  to do whats best for patients
• Infrastructure helpGuidelinesInformation
  TechnologyNurse Care managementSelf-management
  Support
• Active program of practice change
• Networking of professionals

29
Contact us

• www.improvingchroniccare.org

thanks