Organization of Diabetes Care

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Organization of Diabetes Care

• Alireza Esteghamati,MD
• Professor of Endocrinology and Metabolism
• Tehran University of Medical Sciences

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The Chronic Care Model

• Improving Care for People Living with diabetes

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Objectives

• Define the problem in todays health care systems
• State 5 useful aims to keep in mind while seeking
  to improve care
• Describe the development of the Chronic Care
  Model (CCM)
• List the 6 components of the CCM

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Key Points

1. Diabetes is a chronic disease that requires
   proactive, planned and population-based care
2. It takes a team. Diabetes care should involve a
   interdisciplinary team working within the chronic
   care model
3. Technology (telehealth, reminder systems, EMRs,
   etc.) can be used to improve care

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A New Health system for the 21st Century

• The current care systems can not do the job.
• Trying harder will not work.
• Changing care systems will.

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Six Aims for Improving Health Systems

• Safe avoids injuries (no needless deaths,
  accidents, or injuries)
• Effective relies on latest scientific knowledge
• Patient-centered responsive to patient needs,
  values, and preferences
• Timely avoids delays
• Efficient avoids waste
• Equitable quality unrelated topersonal
  characteristics (everyone, everywhere can receive
  )

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Implications for How to Change Practice

• If the problem is the system, and not the
  individual bad apples, then the focus for
  practice improvement needs to shift.
• Need to make the right thing to do the easy thing
  to do.

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Usual Chronic Illness Care

• 15 minute visit, poorly organized
• Symptoms and lab results focus of discussion and
  exam, not preventive assessment
• Patients attempts to discuss difficulties in
  living with the condition are discouraged

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Usual Chronic Illness Care

• Focus is on physicians treatment, not patients
  role in management.
• Treatment plan is limited to prescription refill
  and encouragement to make appointment if not
  feeling well
• Visit ends with physician rifling through drawers
  looking for a pamphlet

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Rationale for Population Based Care The current
care delivery system was design for acute
episodic care and does a poor job for chronic and
preventive care. Until there is fundamental
system change we will not do much better than the
following

• Evidence based care given only 55 of time
• (NEJM. 2003348(26)2635-2645)
• Blood sugar is controlled in only 37 of patients
  with diabetes
• (JAMA. 2004291(3)335-342)
• Blood Pressure is controlled in only 35 of
  patients with hypertension
• (Ann Intern Med. 2006145(3)165-175)
• Every system is perfectly designed
• to get the results it gets

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Usual Care Model
Health System

• Health Care Organization
• Leadership concerned about the bottom line
• Incentives favor more frequent, shorter visits
• No organized QI

Community

• Resources and Policies
• No links with community agencies or resources

Clinical Information Systems Dont know pts or
what they need
Self-Management Support No systematic approach
didactic in orientation
Decision Support No agreement on good care
traditional referrals
Delivery System Design Reliance on short,
unplanned visits
Frustrating Problem-Centered Interactions
Uninformed, Passive Patient
Unprepared Practice Team
Sub-optimal Functional and Clinical Outcomes
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Usual Care Model
Unprepared Practice Team
Uninformed, Passive Patient
Sub Optimal Functional and Clinical Outcomes
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Reality Guidelines are NOT Followed

• Care gap between diabetes management guidelines
  and real-life practice
• Organizational and evidence-based approach to
  treating chronic diseases

Real Life
Ideal Practice
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Chronic Care for a Chronic Disease

• Acute and reactive
• Proactive, planned, and population-based

The Chronic Care Model
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To Change Outcomes Requires Fundamental Practice
Change

• Reviews of interventions in several conditions
  show that effective practice changes are similar
  across conditions.
• Integrated changes with components directed at
• Influencing physician behavior
• Better use of non-physician team members
• Enhancements to information systems
• Planned encounters
• Modern self-management support
• Care management for high risk patients

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System Change ConceptsWhy a Chronic Care Model?

• Emphasis on physician, not system, behavior.
• Characteristics of successful interventions
  werent being categorized usefully.
• Commonalities across chronic conditions
  unappreciated.

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Chronic Care Model
Informed, Activated Patient
Supportive, Integrated Community
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes
Satisfaction ? Clinical Measures ? Cost ?
External Review Measures
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Themes in the Chronic Care Model

• Evidence-based
• Valuing excellence (and evidence) over autonomy
• Patient-centered
• Each patient is the only patient
• Population-based

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The Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
DeliverySystem Design
Decision Support
ClinicalInformationSystems
Family Education Self- Management Support
Informed, Activated Patient
Prepared, Proactive Practice Team
Supportive, Integrated Community
Productive Interactions
Functional and Clinical Outcomes
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Elements of the Chronic Care Model
2. Self-Management Support
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Chronic Care Model
Community Resources and Policies
Health System
Health System Health Care Organization
ClinicalInformationSystems
DeliverySystem Design
Family Education Self-Management Support
Decision Support

• Specific goals in organizations
  strategic/business plan
• Senior leader support
• Organization adopts performance improvement
  model
• Provider incentives support organizational goals

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Health Care Organization

• 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.

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
DeliverySystem Design
ClinicalInformationSystems
Decision Support
Family Education Self- Management Support

• Evidence-based guidelines
• Provider education
• Referrals and specialist expertise
• Guidelines for patients

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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.

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Decision Support

• Tools and techniques to improve patient care
  decisions
• Flow sheets, electronic medical records (EMRs),
  care algorithms, accessible specialist support,
  education, etc.
• Most helpful if available at point of care

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Chronic Care Model
Community Resources and Policies
Health System
Health Care Organization
DeliverySystem Design
Family Education Self-Management Support
Decision Support
ClinicalInformationSystems

• Emphasize patient/parent active role
• Collaborative care planning/problem solving
• Ongoing educational process
• Connections between family/patient and social
  support
• Standardized assessments of self-management
• Written management plan with goal setting

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Self-Management Support

• Formerly known as Diabetes Education
• Shift from didactic diabetes education to a
  patient-empowering motivational approach
• Problem-solving and goal-setting

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Self-Management Support

• Emphasize the patient's central role.
• Use effective self-management support strategies
  that include
• assessment
• goal-setting
• action planning
• problem-solving
• follow-up.
• Organize resources to provide support.

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Chronic Care Model
Health System
Community Resources and Policies
Health Care Organization
ClinicalInformationSystems
Decision Support
DeliverySystem Design
Family Education Self-Management Support

• Team roles and tasks (practice team, school,
  parents)
• Care based on accepted guidelines
• Primary care team assures continuity
• Regular follow-up care

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Delivery System Design

• Define roles and distribute tasks among team
  members.
• Use planned interactions to support
  evidence-based care.
• Provide clinical case management services for
  high risk patients.
• Ensure regular follow-up.
• Give care that patients understand and that fits
  their culture.

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Delivery Systems Design The Team

• Expertise of nurses, dietitians, pharmacists, and
  psychological support
• Team working with primary care physicians
  supported by specialists
• Disease management model that uses patient
  education, coaching, treatment adjustment,
  monitoring, care co-ordination

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Your diabetes care team may include a .
You
Optometrist or ophthalmologist
Local diabetes education centre
Kidney specialist
Physical activity specialist
YOU
Dentist
Heart specialist
Family and friends
Mental Health Professional
Foot care specialist
Other people you know who have diabetes
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Chronic Care Model
Community Resources and Policies
Health System
Health Care Organization
ClinicalInformationSystems
Family Education Self-Management Support
DeliverySystem Design
Decision Support

• Registry to track clinically useful and timely
  information
• Registry reports/data for feedback
• Care reminders
• Assure timely planned follow-up
• Identification/proactive care of relevant
  patient subgroups
• Individual patient care planning

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Clinical Information Systems

• 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.

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Chronic Care Model
Community Resources and Policies
Health System
Health Care Organization
ClinicalInformationSystems
DeliverySystem Design
Family Education Self-Management Support
Decision Support

• Partnerships
• Key school contact identified
• Input
• Educational services available

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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.

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How Would I Recognize Good Care for People with
Chronic Illness?
Informed, Activated Patient
Supportive, Integrated Community
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes

• Assessment and tailoring
• Collaborative problem definition
• Evidence-based clinical management
• Goal-setting and problem-solving
• Shared care plan
• Active, sustained follow-up
• Community integration and support

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A Recipe for Improving Outcomes
System change strategy
Learning Model
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Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
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What characterizes an informed, activated
patient?
They have the motivation, information, skills,
and confidence necessary to effectively make
decisions about their health and manage it.
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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
  patients self-management
• The provider is viewed as a guide on the side,
  not the sage on the stage!

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What characterizes a prepared practice team?
Prepared Practice Team
At the time of the interaction they have the
patient information, decision support, and
resources necessary to deliver high-quality
care.
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Prepared Practice Team

• Has the
• Patient information
• Decision support
• People
• Equipment
• Time

• To deliver
• Evidence-based clinical management
• Self-management support

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How would I recognize a productive interaction?
Prepared Practice Team
Informed, Activated Patient
Productive Interactions

• 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.

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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.

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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.

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Self-Management Education
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Self-Management Education (SME)

• A systematic intervention that involves
• active patient participation
• in self-monitoring and/or
• decision-making

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Key Points

1. Diabetes self-management education (SME) improves
   health parameters
2. SME should teach behaviours as well as knowledge
   and technical/problem-solving skills
3. SME should be patient-centred, tailored to the
   individual, use a variety of teaching methods and
   be regularly reinforced

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Knowledge is Power

• Empowering patients through self-management
  education improves
• A1C
• Quality of life
• Weight loss
• Cardiovascular fitness

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Basic Knowledge and Skills

• Monitoring health parameters (including SMBG)
• Healthy eating
• Physical activity
• Pharmacotherapy and medication adjustment
• Hypo-/hyperglycemia prevention/management
• Prevention and surveillance of complications
• Problem identification and solving

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Not Just Knowledge Work on Behavior!

• Cognitive-behavioral interventions improve
  self-management and metabolic outcomes
• They may involve
• Cognitive re-structuring
• Problem-solving
• Cognitive-behavioural therapy (CBT)
• Stress management
• Goal setting
• Relaxation

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How should SME be delivered?
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Diabetes Education Improved!

• Collaborative and interactive
• Patient-centred and individualized
• Knowledge and technical skills, but also
  problem-solving skills
• Repeatedly reinforced
• Educational, psychological, and behavioral
  interventions and a variety of teaching methods

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Steps to Success
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Self-Management Support

• This section contains
• 5As Self-Management support forms
• Goal Setting form
• Patient education handouts

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Using the 5 As With Diabetes

• Assess
• Advise
• Agree
• Assist
• Arrange

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Using the 5 As With Diabetes

• Assess What does the patient know about
  diabetes. Are they ready to learn? What are
  their values and culture?
• Advise Prioritize an individual plan for your
  patient in partnership with them.
• Agree Start with goals patient has identified
  and assist them in creating ways to meet their
  goals.

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Using the 5 As With Diabetes

• Assist Develop a long-term plan for the patients
  which is agreed upon by both patient and
  provider. Assist patient in identifying barriers
  to success.
• Arrange Continue to follow-up and assist patient

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5As Self Management Support Form Specific for
Diabetes
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5As Self Management Support Form Generic for any
condition
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Patient Education Tools

• Help patients prepare for, and know what to
  expect from, a diabetes visit

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Diabetes Self Management Goal Setting Form
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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Patient Education Handout
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The Chronic Care Model (CCM) Saves Lives

• The CCM improves
• A1C
• LDL-C
• Use of statins
• Drug and hospital expenditures
• Overall mortality

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