The Chronic Care Model

ICIC Website: http://www.improvingchroniccare.org/

The Chronic Care Model

Mike Hindmarsh

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

California Chronic Care Learning Communities Initiative Collaborative

Oakland, CANovember 2-3, 2004

Three Biggest Worries About Having A Chronic Illness (Age 50 +)

1. Losing Independence

2. Being a Burden to Family or Friends

3. Not Being Able to Afford Needed Medical Care

Percent Somewhat or Strongly Disagreeing With Statements

Age 50-64 Age 65+

Government programs are adequate to meet the needs of people with chronic medical conditions

Health insurance pays for most of services chronically ill people need

People with chronic medical conditions receive adequate medical care

65%

55%

66%

47%

43%

52%

Number of Chronic Conditions per Medicare Beneficiary

Number of Conditions

Percent of Beneficiaries

Percent of Expenditures

0 18 1

1 19 4

2 21 11

3 18 18

4 12 21

5 7 18

6 3 13

7+ 2 14

63%63% 95%95%

The Growing Burden of Non-communicable Disease

• Rapidly aging population

• Increased environmental risks—smoking, changed diet, increasing inactivity, air pollution

• Double jeopardy: still fighting infectious disease and malnutrition while experiencing impacts of chronic disease

W.H.O. Innovative Care for Chronic Conditions, 2002W.H.O. Innovative Care for Chronic Conditions, 2002

Prevalence of chronic conditions

• 10.3 % have heart disease

• 23% have HTN

• 9.1% have asthma

• 6.2% have diabetes

• Prevalence of HTN and diabetes increased in Hispanics and blacks

The Burden of Chronic Illness on The Acute Care System

Additional Diagnoses* 45%

Functional Limits** 50%

> 2 Symptoms*** 35%

Poor Health Habits 30%

*Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung 17%)** Physical (31%), pain (28%), emotional (16%), daily activities (16%)*** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue(23%), foot (21%), backache (20%)

The Average Patient with Diabetes has:

Diabetes Care in the U.S.Harris. Diab Care 2000;23:754-8

0%

20%

40%

60%

80%

100%

HbA1c<8

BP<140/90

LDL<130

ASA Use

Eye Exam

Flu Shot

Use of statins in pts with MI

• 60% of patients over age 65 with a history of a heart attack were on a cholesterol-lowering medication

• 33% knew the result of their most recent cholesterol measurement

Ayanian et al Arch Inter Med 2002;162:1013

Hypertension care in US

• Over 16,000 patients

• 27% had hypertension

• 15-24% had controlled hypertension

• 27-41% unaware that they had hypertension

• 25-32% had treated uncontrolled hypertension

• 17-19% aware of hypertension but it was untreated

NEJM 2001;345:479-486

Physician treatment practices for hypertension

• 41% had not heard of JNC guidelines

• JNC guidelines recommend treatment to 140/90

• 43% of MDs would not start therapy unless systolic >160 and 33% would not start treatment unless diastolic >95

• Most would choose ACE for first drug

Hyman et al Arch Inter Med 2000;160:2281

The IOM Quality report: A New Health System for the 21st Century

http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

The IOM Quality Report:Selected Quotes

• “The current care systems cannot do the job.”

• “Trying harder will not work.”

• “Changing care systems will.”

Systems are perfectly designed to get the results they achieve

The Watchword

Improving Chronic Illness CareA national program of the Robert Wood Johnson Foundation

Mission

to improve the health of chronically ill patients

by helping health plans and provider groups,

especially those that serve low income

populations, improve their care of the

chronically ill.

Evidence-basedClinical ChangeConcepts

A Recipe for Improving Outcomes

LearningModel

System ChangeConcepts

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

System change strategy

Select Topic

Planning Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Action Period Supports

E-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Event

A D

P

S

(12 months time frame)

System Change ConceptsWhy a Chronic Care Model?

• Emphasis on physician, not system, behavior

• Characteristics of successful interventions weren’t being categorized usefully

• Commonalities across chronic conditions unappreciated.

Model Development 1993 --• Initial experience at GHC

• Literature review

• RWJF Chronic Illness Meeting -- Seattle

• Review and revision by advisory committee of 40 members (32 active participants)

• Interviews with 72 nominated “best practices”, site visits to selected group

• Model applied with diabetes, depression, asthma, CHF, CVD, arthritis, and geriatrics

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Improved Outcomes

Essential Element of Good Chronic Illness Care



PreparedPractice Team

What characterizes a “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

What characterizes a “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 patient’s

self-management. The provider is viewed as a guide on the side, not the sage on the stage!


•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




How would I recognize aproductive interaction?



Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community


Chronic Care Model

Improved Outcomes

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

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

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

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.

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.


• 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.

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.

To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change

• Interventions focused on guidelines, feedback, and role changes can improve processes

• Interventions that address more than one area have more impact

• Interventions that are patient-centered change outcomes.

Renders et al, Diabetes Care, 2001;24:1821

Impact of Planned Care and Collaborative Goal-Setting

• Randomized Danish GPs to diabetes intervention groups

• Intervention group trained to provide regular goal-setting in periodic structured visits with their diabetic patients

• Study team provided guidelines, training, reminders, and regular feedback

• Mean HbA1c significantly better years later

Olivarius et al. BMJ 10/01

Advantages of a General System Change Model

• Applicable to most preventive and chronic care issues

• Once system changes in place, accommodating new guideline or innovation much easier

• Early participants in our collaboratives using it comprehensively

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

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

Regional Collaboratives (cont’d)• Maine: Diabetes

• Rhode Island: Diabetes I, II

• Arizona: Diabetes

• North Carolina: Diabetes

• New York: Asthma and Prenatal Care

• Indiana Chronic Disease Management Program

• New York Health and Hospital: Diabetes & CHF

• British Columbia: CHF and Diabetes

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

• HbA1cs, LDLs and BPs are reduced

RAND Evaluation questions

– Do organizations in a collaborative learning environment 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

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

•www.improvingchroniccare.org

Contact us:

thanks

Documents

The Chronic Care Model