Redesigning Chronic Illness Care: The Chronic Care Model

1. Redesigning Chronic Illness Care:The Chronic Care Model Ed Wagner, MD, MPH 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 IHI National Forum December 10, 2007

2. Chronic Illness in America • More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them. • Despite annual spending of well over $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care. • Gaps in quality care lead to thousands of avoidable deaths each year.. • Patients and families increasingly recognize the defects in their care.

3. Chronic Illness and Medical Care • Primary care dominated by chronic illness care • Clinical and behavioral management increasingly effective BUT increasingly complex • Inadequate reimbursement and greater demand forcing primary care to increase throughput—the 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 are new models of primary care and growing interest in changing physician payment to encourage and reward quality

4. What Patients with Chronic Illnesses Need • A “continuous healing relationship” with a care team and practice system organized to meet their needs for: • Effective Treatment (clinical, behavioral, supportive), • Information and support for their self-management, • Systematic follow-up and assessment tailored to clinical severity, • More intensive management for those not meeting targets, and • Coordination of care across settings and professionals

5. 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.”

6. What’s Responsible for the Quality Chasm? • A system oriented to acute disease that isn’t working for patients or professionals

7. What kind of changes to practice systems improve care?

8. Randomized trials of system change interventions: Diabetes Cochrane Collaborative Review • 41 studies, majority randomized trials • Interventions classified as provider-oriented, organizational, information systems, or patient-oriented • Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included • All 5 studies with interventions in all four domains had positive impacts on patients Renders et al, Diabetes Care, 2001;24:1821

9. The Effectiveness of QI Strategies: Findings from a Recent Review of Diabetes Care Shojania, K. G. et al. JAMA 2006;296:427-440.

10. Toward a chronic care oriented system Reviews of interventions in other conditions show that practice changes are similar across conditions Integrated changes with components directed at: • use of non-physician team members, • plannedencounters, • modern self-management support, • Intensification of treatment • care management for high risk patients • electronic registries

11. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

12. What distinguishes good chronic illness care from usual care? Prepared Practice Team Informed, Activated Patient Productive Interactions

13. Prepared Practice Team Informed, Activated Patient Productive Interactions How would I recognize a productive interaction? Assessment of self-management goal attainment and confidence as well as clinical status Adherence to guidelines Tailoring of clinical management by stepped protocol (Treat to target) Collaborative goal-setting and problem-solving resulting in a shared care plan Planning for active, sustained follow-up

14. Informed, Activated Patient What characterizes an “informed, activated patient”? They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.

15. Self-Management Support Goal To help patients take a more active role and be more competent managers of their health and healthcare.

16. Community Resources and Policies Goal To help patients access effective and useful services and resources in the surrounding community.

17. What characterizes a “prepared” practice team? Prepared Practice Team Practice team and interactions with patientsorganized to help patients reach clinical targets and self-management goals..

18. Delivery System Design Goal To organize practice staff, schedules and other systems to assure that all patients receive planned, evidence-based care.

19. Decision Support Goal To assure that clinicians and other staff have the training, scientific information and system support to routinely provide evidence-based (adhere to guidelines) and patient-centered care.

20. ClinicalInformation System Goal To assure that clinicians and other staff have ready access to patient information on individuals and populations to help plan, deliver and monitor care.

21. Health Care Organization Goal To assure that practices within the organization have the motivation, support and resources needed to redesign their care systems.

22. Does the CCM Work? The Evidence Base

23. Organizing the Evidence • Randomized controlled trials (RCTs) of individual interventions to improve chronic care • Studies of the relationship between organizational characteristics and quality improvement • Evaluations of the use of the CCM in Quality Improvement • RCTs of CCM-based interventions • Cost-effectiveness studies

24. 1: RCTs of interventions to improve chronic care results Studies in other conditions confirm that the elements found effective in diabetes care apply to other chronic conditions as well.

25. 2: Studies of the Relationship between Organizational Characteristics and Quality • Studies measure adherence to the CCM via self-assessment or external observer • Analyses either compare high and low performers or correlate degree of CCM implementation with performance • Studies show that quality improves with fuller implementation of the CCM • Most studies cross-sectional; don’t answer the question whether going to trouble of redesigning practice improves performance.

26. Several studies have demonstrated a relationship between practice characteristics consistent with the CCM and performance Study of in 20 Texas Primary Care Practices • Practices evaluated themselves using the ACIC • Researchers reviewed diabetic charts • Analysis looked at relationship between ACIC scores and 10 yr. risk of CHD (HbA1c, BP, LDL, smoking) • Higher ACIC associated with reduction in modifiable CHD risk (full implementation of CCM reduced average risk over 50%). Parchman et al. Medical Care, Dec. 2007

27. 3: Evaluations of the Use of CCM in Quality Improvement 3 major evaluations- RAND Evaluation of ICIC collaboratives- Landon evaluation of the Health Disparities collaboratives- Chin evaluation of HDC in the midwest All studies focus on diabetes Methods differed- RAND compared collab. participants withother practices in the org.- Landon compared entire CHCs that were and were not involved in the HDC with 1 yr. follow-up- Chin looked at entire CHCs involved in the HDC over 4 year period

28. 3: RAND Evaluation of Chronic Care Collaboratives • Two major evaluation questions:1. 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

29. 3: RAND FindingsImplementation of the CCM • Organizations made average of 48 changes in 5.8/6 CCM areas • IT received most attention, community linkages the least • One year later, over 75% of sites had sustained changes, and a similar number had spread to new sites or new conditions.

30. 3: RAND Findings: Patient Impacts • Diabetes pilot patients had significantly reduced CVD risk (pilot > 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

31. 3: Evaluations of the Health Disparities Collaboratives • Landon evaluation showed process but not outcome improvements in the year following the end of participation • Chin showed process improvements in the following year followed two years later by significant reductions in HbA1c and LDL. • My hunch: Participating practices saw short-term improvements in both process and outcomes (RAND), and the spread of process changes to other practices in the system began shortly thereafter, but was slow and didn’t impact clinic-wide outcomes for another year or two.

32. 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

33. 5: Cost Study Results • Some evidence that improved disease control can reduce healthcare costs, especially for congestive heart failure, asthma (among populations with high ER and hospital use) and uncontrolled diabetes • Better depression control does not appear to reduce healthcare costs, but increases work productivity • Huang et al. showed that HDC participation had a favorable CE ratio

34. Challenges in Implementing the CCM • Practices spent considerable time searching for/developing tools • Some practices felt intimidated by taking on the whole model – asked for a sequence • Many changes were made in ways that were not sustainable logistically or financially (e.g., double data entry) • CCM elements implemented as “special events” rather than part of routine care • Many achieve process improvements but outcomes don’t change

35. Why do practices who have changed their system not see improvements in key outcome measures (e.g., measures of disease control)? The systems aren’t in placeto get every patient to target! • Patients are getting regularplanned interactions • Limited ability to intensify management of patients not meeting goals

36. What are the barriers? • QI efforts limited to “early adopters” • The hamster wheel • Belief in the quality of one’s practice – i.e. no meaningful measurement • Underdevelopment of practice team • Inability to access or use information technology or non-physician staff to improve patient care • Practice isolation • Fee-for-service reimbursement that doesn’t reward high quality care, in fact discourages it

37. If you could fully implement the Chronic Care Model: How would the care of your average chronically ill patient be different? How would their experience change?

38. If you could fully implement the Chronic Care Model: How would the day to day experience of the clinical staff be different? Do you think work satisfaction would change?

39. Contact us: www.improvingchroniccare.org thanks

40. Self-Management Supportand Community Resources Judith Schaefer, MPH 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 IHI National Forum December 10, 2007

41. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

42. FACTS AND FICTIONS • Diabetes is the leading cause of adult blindness, amputations and kidney failure. True or false? ________________________________________ A. False. Poorly controlled diabetes is the leading cause of adult blindness, amputations and kidney failure.

43. Setting the Stage for Change

44. Differences Between Acute and Chronic Conditions

45. Differences Between Acute and Chronic Care Roles

46. Symptom Cycle Disease Fatigue Tense muscles Vicious Cycle Depression Stress/Anxiety Anger/Frustration/Fear

48. Persuasion Techniques • Agree that speaker should make the change • Explain why the change is important • Warn of consequences of not changing • Advise speaker how to change • Reassure speaker that change is possible • Disagree if speaker argues against change • Tell the speaker what to do • Give examples of others (other patients, peers, celebrities) who have made similar healthy changes

50. The Patient-Focused Approach • BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job. • KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management