The Planned (Chronic) Care Model : A Framework for Improving Care for Your Patients

1. The Planned (Chronic) Care Model:A Framework for Improving Care for Your Patients Julie Osgood • Peg Cyr, MD MaineHealth May 3, 2007

2. Objectives • Describe model for improving chronic illness care and prevention that is… • Patient-centered • Interdisciplinary • Evidence-based • Demonstrate how the Planned (Chronic) Care Model can provide an effective framework for practices to improve care

3. Planned Care – Key Concepts A planned care approach needs… • A care team that truly functions as a team • Patients who are informed, encouraged, and equipped to have an active role in their care • Use of care plans that are proactively designed & delivered • Clinical information system(s) that supports patient and care team • Leadership that drives & supports these elements

4. “Systems are perfectly designed to get the results they achieve”-Paul Batalden

5. Current “Systems”

6. Time for a Different Approach? • Emphasis for change to date has been on physician, not system • Characteristics of successful, evidence-based interventions weren’t being categorized usefully • Common interventions that improve outcomes across chronic conditions not fully appreciated

7. Essential Elements of Good Care Informed, Activated Patient Prepared Practice Team Productive Interactions Improved Outcomes

8. Planned (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

9. Self-Management Support • Support patient’s ability to manage their own condition • Identify what’s important to your patient • Use effective behavior change methods • Make the patient a partner in care – can require a culture shift!

10. Self-management Support • Use standard, basic patient education materials to give repeated, consistent messages • Use self-care tools (e.g. self-care card, goal-setting sheets), assess confidence, identify barriers for making change • Encourage referrals for formal self-management education and training (e.g. diabetes self-management training, asthma education, cardiac rehab)

11. Think differently! Focus on collaborative goal setting with patients Effectively support behavior change with patients: Do you want to make a change? How are you going to make the change? What can I do to help you? Moving beyond “compliance”… “Non-compliant patient”

12. How important is the change to the patient? How confident are they that they can make the change? Collaborative Goal-Setting Tools 1 2 3 4 5 6 7 8 9 10 • What barriers are likely to get in the way?

15. Create a supportive practice team Doc can’t do it alone – need everyone to work up to their full capacity Everyone has a role – identify and train staff to maximize their role Delivery System Design

17. What Characterizes a “Prepared” Practice Team? • At the time of the visit, the care team has… • patient information • decision support • people, equipment, and time • … required to deliver evidence-based clinical management and self-management support

18. Redesigning the Care Team • Use “planned care” visits (can’t rely on just acute care visits) • - Prepare patient for visit (bring meds, devices) • - Use visit templates, flow sheets, standing orders • Provide follow-up care according to guideline recommendations • Consider alternative care models – e.g. group visits, follow-up phone calls

19. Can’t rely on memory alone! (think of flying…) Get tools into practice to help providers make the right decision – every time! Translate guidelines into practice! Clinical Decision Support

20. Clinical Decision Support • Embed guidelines into practice by using practical tools, algorithms - e.g. Asthma flow sheets; COPD-Asthma Algorithm • Encourage case-based learning, alternative models for provider education • Integrate specialist expertise when needed

22. Use data to track care & outcomes – any system can work! Can’t measure what you can’t improve Use your data to improve the health of individuals and populations – don’t need to wait for EMR! Clinical Information Systems

23. Clinical Information Systems • Any system will do • EMR – IF have way to look at outcomes • Electronic registry • Paper systems • Use clinical information systems (registry) to… • Summarize key issues at point of care • Create provider, practice reports to periodically monitor performance, provide data feedback • Identify high-risk pt subgroups needing proactive care

26. Recognize practice as situated within larger community – do you know your community? Form partnerships with local community resources Strengthen connections with local Healthy Maine Partnerships Raise public awareness through community education Community Resources

27. 31 Healthy Maine PartnershipService Areas

29. But Does It Work???

30. How One Team at MMC Family Medicine Center Made It Real!

31. MMC Family Medicine Center • Greater Portland community & beyond • Traditionally the area’s underserved population • We serve 21,000+ diversified patients(between the 2 sites) • More than 52 languages • An increasing number of immigrants and refugees • Out of those 21,000+ patients – 1,917 have been diagnosed with asthma

32. Blue Hill Team • One of three teams in Portland • Consisting of: • 3 faculty • 6 residents • 1 Nurse Practitioner • and 5 clinical staff

33. Getting Started: Participation in an Asthma Collaborative • To improve classification and care for asthma patients and enhance education to providers and staff. • To decrease acute visits for exacerbations and eliminate asthma related hospitalizations and ED visits.

34. Where we started • Identified Asthma Pts • Med Records audit • Sent out letters • “Pop-ups” in Logician & “sticky notes” in GPMS • Printing list of asthma pts w/ OV for the day Chronic Care Model: Delivery System Design, Information Systems, Decision Support

35. Asthma pop-ups

36. Reorganized workspace • Asthma folder located @ team desk • Peak flow meters & spacers in rooms Chronic Care Model: Delivery System Design

37. Created Asthma triggers • Asthma roles & responsibility cards • Education materials in exam rooms & in EMR (flipcharts) • LRC displays & materials Chronic Care Model: Patient Self Management, Delivery System Design, Information Systems

38. Chronic Care Model: Delivery System Design, Community Resources

39. Asthma Folder

40. Education Materials in Exam Rooms For patient For provider Patient Education and Self-Management Support Decision Support

41. Accomplishments • 90-100% classified • 100% of persistent asthma patients on controller medication • Access to peak flow meters & spacers • Increase in # of referrals • Redesign of workflows • Tracking our numbers and progress • Utilizing Asthma Metrics and the CIR

42. How can YOU Make the Care Model “Real”? • Support patients to understand, manage their own condition(s) • Build on evidence-based guidelines • Use the tools! • Lots of locally-developed patient & provider tools! • Get support for change: MH Learning Community! • Educational sessions - Learn from peers • Tools - Coaching • Use “rapid cycle” framework for change (PDSA!)

43. For more info: • Planned (Chronic) Care Model references • www.improvingchroniccare.org • www.mainehealth.org Adapted from presentation by Ed Wagner M.D, MPH, Macoll Institute, Group Health Puget Sound