Chronic Illness A New Model of Care

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Chronic Illness A New Model of Care

• Kayla Brodkin MD
• Department of Gerontology and Geriatric Medicine
• Puget Sound Veterans Administration Health Care
  System

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What is Chronic Care and Why Do We Care Anyway?

• Demographic estimates 99M Americans live with
  chronic illness, most with gt1 chronic illness,
  88 of gt65y have gt1 chronic disease, 25 of which
  have gt4
• Projections of increased complexity of care in
  future
• Aging and improved medical therapies contributing
  to increased prevalence, severity and complexity
  of chronic disease in US
• Chronic illness accts for 75 national health
  care costs

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Chronic Disease the transformed patient

• Requirements for continuous care management
• Continuity of care becomes cornerstone in
  management
• Self-management increasingly required
• Patient education key to promoting autonomy,
  responsibility and self-advocacy
• Caregiver support increasingly important

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Acute v Chronic Medical Care

• Chronic Care
• Continuous/dynamic
• Non-curative
• Co-managed (doctorlt-gtpatient)
• Expanded care model
• (case-management/multidisciplinary team)
• Expanded sites of care and mode f/u
• (hospital/clinic/snf/home telephone/email)
• Evidence supports improved
• morbidity/mortality/satisfaction/QOL/cost

• Acute Care
• Episodic
• Curative
• Hierarchical (Doctor-gtpatient)
• Single care provider
• Single site of care
• Outcomes evidence

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Chronic Diseases

• HTN
• DM
• CHF
• OA
• COPD
• Cancer
• Mental Health Illness- depression/ dementia/
  psychosis etc
• Chronic Infectious Diseases HIV/AIDS, Hepatitis

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Changing Demographics in America
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Traditional Approach

• Clinical presentation -gtDDX -gtTesting-gtDx-gtTherape
  uticgtOutcome

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Traditional Approach

• Clinical presentation -gtDDX -gtTesting-gtDx-gtTherape
  utics-gtOutcome
• hx
• Cough Infection CXR pna
  abx sx resolution
• Dyspnea CBC
• sputum
• phys findings
• Rhonchi
• Wheeze
• Fever

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Chronic Care Approach
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Chronic Care Approach

• Increased Complexity- medical/psychosocial
• Interdependent variables
• Patient expectations and values (autonomy)
• Requires individualized approach
• Multidisciplinary
• Resource intense

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A Case 90 yo hospitalized with ACS s/p stent
placement whose hosp complicated by delirium and
chf now ready for discharge
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Issues for consideration

• Patient preferences
• Functional status- newly acquired weakness
  (decreased ability to transfer and toilet w/o
  help) permanent v transient
• Availability of social supports
• Patients ability to manage own symptoms
• Availability of additional resources
• Safety of returning to previous living situation

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Case

• Pt preference to return home to independent
  living
• Weakness and ADL deficiency addressed by
  rehabilitation effort (10 d subacute stay TCU)
• Anticoagulation and cardiac meds monitored by
  home care nursing (VNS)
• Mediset provided, home venipuncture, sx
  surveillance
• Enhanced involvement of family
• Issuance of life-alert system for safety

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Chronic Care Team

• MD- managed medical aspect of care, medications,
  consulted hospital resources (anticoagulation
  team, VNS) and arranged for medical follow-up
• Social Worker- developed strategy for discharge
  to bridge community resources (VNS, MOW),
  enlisted family support, arranged transportation
  (discharge, resume Access), facilitated lifeline
• Physical Therapist- assessed falls risk
  gait/station
• developed plan for strengthening LE and
  maintenance, arranged for home safety evaluation,
  issued equipt for home use
• Occupational Therapist- assessed ADLs, provided
  equipt for home use (energy conservation)
• Pharmacist- assessed meds for potential
  interactions, provided mediset

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Chronic Care Model (Wegner 96)

• Model of primary care for chronic illness
• Improve management and outcomes
• Group Health Cooperative- novel modalities for
  management diabetes
• Requires rethinking of practice
• Involves entire community (include resources) and
  policies (public and private)
• Healthcare system (including payment str)
• Provider organization

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Elements for Successful Implementation

• Community resources and policies- linkage with
  community based resources (ie senior ctr,
  exercise prog, self-help grps)
• Heath care organizational structures- seen as
  priority, goals and values to support effort,
  financial advantage (dec cost, incr revenue)
• Self- management support- patient become
  principal caregiver- self management centerpiece
  of design (tools provided), patient education
  essential
• Delivery system design- practice teams with clear
  division of labor, planned visits important part
  of design
• Clinical information systems- decisional support
  based on evidence-based clinical practice
  guidelines to provide standards for optimal care-
• Clinical information systems allow for improved
  communication/reminders/surveillance/performance
  measure monitoring

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Chronic Care Evidence (JAMA 2002)

• Diabetic care does implementation of the chronic
  care model improve care of diabetic pt?
• Cochrane reviews ambulatory care diabetic
  management
• 1294 citations 41 studies/200 practices/48,000
  pt included
• Eval for which of 4 ch care model components
  include as pt of study intervention
• Self management/decision support/delivery
  system design/clinical info system
• Outcome measures improved process of care
• HgA1C, microalbuminuria, lipids. Patient outcomes
  (end-organ compl

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Chronic Care Model The Evidence

• DM Improved measures of disease control (HgA1C)
• CHF Decreased hospitalizations/Cost of care
• Asthma Decreased hospitalization/cost

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Limitations to Model

• Financial incentives for organization may
  prohibit adopting model for chronic disease
  (fee-for-service model)
• (system favors increased healthcare
  utilization) capitated systems favor model
• Organizational level-need for enlightened
  leadership
• System cannot be carried by single champion

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Chronic Care 2

• Results
• 32/39 studies intervention improved 1 outcome
  meas
• Though studies (5) using 4 meas improvement in
  outcomes, elements and/or which combination of
  elements not determined
• 19/20 studies include self-management improved
  process or outcome of care

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Chronic Care Evidence

• Danish study management DM (Olivarius, DMJ
  2001L323970) RCT 970 p rx by 474
  practitioners-compared usu care to decisional
  support/reg f/u/ remindere sys/self management
  support- indiv goal setting- aft 6 y f/u pt in
  intervention sign lower HgA1C/BP/and chol levles
  than control- mort rates and diabetic compl dn
  differ-

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Chronic Care evidence

• CHF (Rich NEJM1995 1190) nurse dir prog of pt
  educ with posthosp telephone and home visit f/u
  (self-management and suupport and del sys
  redesign) assoc with 50 red in hosp readmission
  for CHF sign impro in QOL scores ct controls
• Asthma (Bolton JGen Int Med 1991 401)self
  management in adult asthmatics decr ED visits
  over 12 m ct usu care, decr hosp los
• DM- decr HgA1C

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Chronic Care Overlapping Galaxies