Title: Improving Chronic Illness Care a quick look at the CCM
1Improving Chronic Illness Carea quick look at
the CCM
- WA State Collaborative to Improve Health
- April 17, 2008
2Objectives
- Identify the six components that comprise the
Chronic Care Model what they are and how they
fit together.
- Summarize the current literature about practices
that have implemented the Chronic Care Model.
- Describe what key changes a practice can make to
improve care for their chronically ill patients.
3Chronic Illness in America
- More than 125 million Americans suffer from one
or more chronic illnesses and 40 million limited
by them.
- Despite annual costs of more than 1 trillion and
significant advances in care, one-half or more of
patients still dont 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.
4Johns Hopkins U.S. Survey about Chronic Care
Agreeing
5The IOM Quality Chasm Report Conclusions
The current care systems cannot do the job.
Trying harder will not work.
Changing care systems will.
6To Change Outcomes Requires Fundamental Practice
Change
- Reviews of interventions in several conditions
show 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, and
- care management for high risk patients
7Chronic 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
8How 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
9Vignettes
10Experience with Collaboratives
- More than 1,000 different health care
organizations and various diseases involved to
date
- Began with national BTS, now regional,
state-based facility specific
- HRSAs Health Disparities Collaboratives-600
community and migrant health centers, now
academic medical centers small practices
- External evaluations of early efforts by Chin et
al., RAND
11RAND Evaluation of Chronic Care Collaboratives
- Studied 51 organizations in four different
collaboratives, 2132 BTS patients, 1837 controls
with diabetes, CHF, asthma
- Controls generally from other practices in
organization
- Data included patient and staff surveys, medical
record reviews
12RAND Findings
- Organizations made average of 48 changes in 5.8/6
CCM areas
- IT received most attention, community linkages
the least
- CHF pilot patients more knowledgeable and more
often on recommended therapy, had 35 fewer
hospital days
- Asthma and diabetes pilot patients more likely to
receive appropriate therapy.
- Asthma pilot patients had better QOL
- Diabetes had significantly better glycemic control
13RCTs of CCM-based interventions
- All but one shows implementation of the CCM
significantly improves process and outcome
measures compared to controls and when included
in the trial less intensive interventions (e.g.
physician training alone). - Team motivation to change may be an important
factor in predicting success.
- Preliminary evidence that collaboratives improve
process measures at the end of 1 year and
outcomes after 3 to 4 years.
14Challenges Remaining
Try less time- intensive learning
Reaching beyond early adopters
Create supportive systems
Target small practices
15Contact us at
www.improvingchroniccare.org