Leadership for Advancing Chronic Care in Challenging Environments California Chronic Care Learning Communities Initiative Collaboration

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Leadership for Advancing Chronic Care in
Challenging EnvironmentsCalifornia Chronic Care
Learning Communities Initiative Collaboration

• Kevin Grumbach, MD
• UCSF and SFGH

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Institute of Medicine2001
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of People in US with a Chronic Illness
1 Chronic Illness
45
57
43
2 or more Chronic Illnesses
Source C Hoffman et al, JAMA 19962761473
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Chronic IllnessPrevalence and Health Costs
Source C Hoffman et al, JAMA 19962761473
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Chronic IllnessRoom for Improvement

• 27 of hypertensives are adequately treated
• Half of discharged CHF patients are readmitted
  within 90 days
• 35 of eligible patients with atrial fibrillation
  receive warfarin
• 74 of diabetics have uncontrolled blood
  pressures, 71 have elevated lipids, and 54 have
  hemoglobin a1c levels above 7.0

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ROOM For ImprovementReprise CHN

• 30 CHF discharges readmitted within 30 days
• 21 diabetics have hemoglobin a1c gt 9.5
• 57 of children with persistent asthma not on
  inhaled steroids

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System ProblemNeeding Systems Solution

• IOM Redesign Imperatives
• Reengineered care process
• Effective use of information technologies
• Knowledge and skills management
• Development of effective teams
• Coordination of care over patient conditions,
  services, sites of care over time

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The Chronic Care Model

• Community Resources
• Health Care Organization
• Delivery System Redesign
• Self-management Support
• Clinical Information Systems
• Decision Support

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Does the Chronic Care Model Work?

• Impact on quality of care
• Impact on costs

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Business Case for Chronic Care Model

• Depends on payor mix and payment incentives
• Uninsured
• Global capitation
• MediCal
• Medicare

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Other Benefits to the Organization

• Treating the chronic ills of safety net culture
• Activated staff
• Culture of improvement and problem solving
• Change is possible

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How can change be created in complex adaptive
organizations?
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Special Challenges forthe Safety Net
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Functional Health Literacy,Diabetic Patients at
SFGH
Source D Schillinger et al, JAMA 2002288475
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Assets of the
Safety Net

• Incentives not always completely misaligned
• Systems and organization
• Talent and commitment

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The Role of Leadership