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Chronic Illness Care A framework for change

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My Mentors Dr Ed Wagner and Michael Von Korff at Group Health in Seattle ... The Chronic Care Model (CCM) Wagner et al Center for Health Studies, Group Health, ... – PowerPoint PPT presentation

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Title: Chronic Illness Care A framework for change


1
Chronic Illness Care A framework for change
  • Malcolm Battersby
  • Associate Professor in Psychiatry
  • Flinders University
  • Flinders Human Behaviour and Health Research Unit

2
Acknowledgements
  • Mary, Ailish and Eve
  • My Mentors Dr Ed Wagner and Michael Von Korff at
    Group Health in Seattle
  • Commonwealth Fund of New York
  • Oh and of course Mum and Dad

3
Angels Landing at Zion
4
Fellowship Activities in the United States
  • Structured literature review of evidence base for
    self-management support
  • Site surveys of mental health and Native American
    self-management programs
  • Participation in 5 Break Through Series
    Collaboratives across the US
  • Training in Lorigs Chronic Disease
    Self-Management Program - Stanford

5
Downtown from Queen Anne
6
Why do we need to change?
  • Chronic disease has overtaken infectious disease
    as the main cause of mortality and morbidity
  • Aging population
  • Increase in chronic disease eg type 2 Diabetes
  • Current system of care is based on an acute model

7
Acute Chronic
  • Ongoing-
  • Stigma attached
  • QOL highly dependent on pts self management and
    decision making
  • QOL highly dependent on ongoing support services
  • Pt often has more knowledge
  • Short term goals to meet long term outcomes
  • Compliance and self reliance expected
  • Episodic
  • Cure expected
  • QOL highly dependent on professional care
  • QOL highly dependent on short term services
  • HP generally the expert
  • Short term goals
  • Compliance expected

8
Sub-optimal PoorCare Outcomes
  • Delays in detection of complications or decline
  • Failures in self-management, or increased risk
    factors as a result of client passivity or
    ignorance.
  • Reduced quality of care
  • Undetected or inadequately managed psychological
    distress
  • Wagner, E., Von Korff, M., et al, Organising Care
    for Patients with Chronic Illness. The Milbank
    Quarterly, Vol. 74, No.4, 1996
  • Irregularor incompleteor inadequate .or
    inconsistent assessment,
  • treatment
  • education, motivation, feedback and /or
    follow up.

9
Poor outcomes because.
  • Poor compliance with medical management by
    patients (50)
  • Poor adherence to behavioural lifestyle changes
    by patients (30)
  • Combined with
  • Poor adherence/compliance by clinicians with
    evidence based medicine and
  • Poor self-management support by clinicians and
  • Poor practice organisation of care

10
Why is Chronic care important?(after McLellan et
al JAMA 243 1689, (2000).
11
The US Health System
  • A disorganised, expensive, inequitable mess
  • And
  • 43 million Americans are uninsured
  • Health accounts for 15 of GDP cf 8-9 in OECD
    countries
  • Despite this or because of it, there is a sense
    that something needs to be done urgently to
    improve quality of care and they are doing
    something about it

12
US Health System
  • Some exemplary services
  • Government Veteran Affairs, Medicare, Medicaid,
    Indian Health Service
  • Private, Health Maintenance Organisations Kaiser
    Permanente, Group Health
  • States Indiana, Washington, New York, California

13
Institute of Medicine Crossing the Quality Chasm
1996 - 2004
  • the burden of harm conveyed by the collective
    impact of all of our health care quality problems
    is staggering (Chassen et al., 1998).
  • There is a chasm (not a gap) between what we
    know to be good quality care and what actually
    exists in practice

14
Harkness (US) Findings
  • Institute for Health care Improvement (IHI)
  • People receive recommended levels of care only
    50 of the time
  • Significant health improvement will come about
    only through a social movement
  • International Priorities
  • Quality improvement reduce errors
  • Redesign systems from acute to chronic illness
    care

15
Evidence for What Works in Chronic Illness
Management
  • The Chronic Care Model (CCM) Wagner et al
    Center for Health Studies, Group Health, Seattle
  • 6 elements for achieving best outcomes for
    individuals and populations
  • The primary outcome is an activated patient

16
Chronic 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
17
Evidence Base for Chronic Care Model (Wagner et
al 1996)
  • Evidence from clinical trials of specific
    practice interventions (case managers,
    guidelines, reminders)
  • Systematic reviews (hundreds of studies) by
    Cochrane Effective Practice and Organisation of
    Care group suggests a synergistic effect when
    multiple interventions are combined, eg
  • Renders et al 2001, (diabetes)
  • Rich et al, 1999 (congest cardiac failure)

18
Chronic Care Model
  • 1. Health System
  • Leadership support for improvement
  • Aligned incentives
  • Care coordination across organisations
  • 2. Community
  • Encourage patients to participate in effective
    community programs
  • Form partnerships with community organisations to
    fill gaps in services

19
Practice Components of CCM
  • 3.Self-management support
  • Emphasise patients central role in managing
    his/her illness
  • Assess patients self-management knowledge,
    behaviours, confidence and barriers
  • Provide effective behaviour change interventions
    and on going peer or professional support

20
Practice Components of CCM
  • 4. Delivery System Design
  • Defines roles and delegate tasks among team
    members
  • Organise practice around planned care
  • Provide case management for complex patients
  • Ensure regular follow-up

21
Practice Components of CCM
  • 5. Decision support
  • Incorporate evidence based guidelines into
    routine care
  • Integrate specialist expertise into primary care
  • Use proven provider education methods
  • Share evidence based guidelines with patients and
    carers

22
Practice Components of CCM
  • 6. Clinical information system
  • Provide reminders for patients and providers
  • Identify sub populations for proactive care
  • Monitor performance of practitioner, practice and
    care system

23
Chronic Care Model Examples
  • 1. Health System
  • Leadership support for improvement
  • Leader incorporates quality into business plan
    and vision
  • Leader effectively communicates quality
    improvement culture
  • Promote multidisciplinary teamwork
  • Aligned incentives
  • Use performance indicators to reward teams
  • Care planning item numbers
  • Care coordination across organisations
  • Develop agreements with other organisations
  • Primary Care Partnerships

24
Chronic Care Model Examples
  • 2. Community
  • Encourage patients to participate in effective
    community programs
  • Create a resource guide
  • Delegate staff member to be community expert
  • Identify evidence based community education
  • Form partnerships with community organisations to
    fill gaps in services
  • Invite community organisations to participate in
    redesign of care
  • Use lay workers to link patients with community
  • Co sponsor an exercise program with a health club

25
Practice Components of CCM
  • 3.Self-management support
  • Emphasise patients central role in managing
    his/her illness
  • Ask patients role in managing their health what
    do you think?
  • Assess patients self-management knowledge,
    behaviours, confidence and barriers
  • Use assessment tools eg Partners in Health
  • Cultural competency training for staff
  • Provide effective behaviour change interventions
    and on going peer or professional support
  • Motivational interviewing, goal setting and
    problem solving

26
Practice Components of CCM
  • 4. Delivery System Design
  • Defines roles and delegate tasks among team
    members
  • Determine business process for planned care eg
    chronic care stream and care planning then
    delegate tasks
  • Use protocols for planned care roles
  • Organise practice around planned care
  • Use a registry to proactively contact patients
    for follow up
  • Provide case management for complex patients
  • Develop patient selection criteria
  • Nurse contact selected patients re
    self-management
  • Ensure regular follow-up

27
Practice Components of CCM
  • 5. Decision support
  • Incorporate evidence based guidelines into
    routine care
  • Use locally adapted guidelines with prompts
  • Integrate specialist expertise into primary care
  • Create an agreed care plan, web based
  • Use proven provider education methods
  • Teach Problem and Goal setting, motivational
    interviewing
  • Regular case conferences
  • Academic detailing
  • Share evidence based guidelines with patients and
    carers
  • Provide care plan, shared decision making CDs eg
    prostate cancer

28
Practice Components of CCM
  • 6. Clinical information system
  • Provide reminders for patients and providers
  • Data base which has information to prompt
    guideline based care eg HbA1c
  • Identify sub populations for proactive care
  • Define criteria for sub populations identify
    nurse to routinely review data based and organise
    care
  • Monitor performance of practitioner, practice and
    care system
  • Use registry to determine percent of patients
    that have not had HbA1c in last 6 months eg
    Congress
  • Audit the next 20 patients with a given diagnosis

29
Evidence for Self-Management
  • Von Korff et al 400 papers, reviews,
    meta-analyses
  • Warsi et al, Archives Int Med, Aug 2004,
    diabetes and asthma
  • Skill based education (knowledge alone is not
    sufficient)
  • Collaborative problem definition
  • Negotiated goal setting
  • Organised follow-up

30
Evidence-Based Principles for Self-Management
Support (SMS) in Primary Care
  • Battersby et al 47 reviews and meta-analyses
  • 12 Principles
  • Multi-faceted interventions are more effective
  • Assessment should guide interventions
  • Skill enhancement benefits patients
  • Counseling should be non-judgmental
  • Goal setting problem solving are effective

31
Evidence-Based Principles for Self-Management
Support (SMS)
  • Interventions should strengthen self-efficacy
  • Case management should be goal-directed
    evidence-based
  • Registries planned follow-up are effective
    tools
  • Diverse providers and formats can be effectively
    employed

32
Collaboratives
  • How to translate research into practice (beyond
    the project)
  • Up to 25 teams meet on 4 occasions over 12
    months,
  • 1-2 day learning sessions
  • The Collaborative has clearly stated 12 month,
    clinical and process outcome goals
  • Teams aim to implement the 6 elements of the CCM

33
Chronic Care Collaboratives
  • 3 different content (disease/condition) areas to
    20 or more participating organisations
  • An improvement method
  • The Chronic Care Model
  • Condition specific content
  • Use the Assessment of Chronic Illness Care tool
    (ACIC) tool to rate improvement of the 6 elements
    of the chronic care model

34
Collaboratives
  • The core process for the teams is the
  • Plan Do Study Act (PDSA) cycle
  • The Team include non clinicians, innovators
  • Set short term 8 day goals
  • Have faculty follow up/support

35
Collaborative Requirements
  • Accountability
  • Creativity
  • Reward and recognition
  • High level leadership support
  • Measurement registry data base to create a
    population focus based on individual patient
    measures

36
Controlled Study
  • Breakthrough Collaborative Series
  • Robert Wood Johnson Foundation 1998, 25
    million
  • Improving Chronic Illness Care
  • Inst for Healthcare Improvement (IHI) and McColl
    Institute (Wagner et al)
  • Use Collaboratives to promote adoption of Chronic
    Care Model with a focus on
  • Diabetes
  • Heart failure
  • Asthma
  • Depression

37
Rand Evaluation of Improving Chronic Illness Care
  • http//www.rand.org/health/projects/icice/findings
    .html
  • Emmett Keeler chief evaluator
  • 36 sites
  • Design Comparison group with usual care
    evaluating processes, outcomes and costs over 12
    months
  • 700 staff, 2,200 intervention and 1,800 controls

38
Rand Evaluation
  • Organisations made an average of 48 changes in
    line with the CCM
  • 81 of organisations made changes in all 6 CCM
    elements
  • 1 year after the changes were introduced, 82 had
    sustained the changes and 79 had spread their
    changes to other areas

39
Clinical outcomes
  • Diabetes patients reduced heart disease risk
    factors from 3.2 to 2.8 compared to no change
    in control group
  • Eye exam increased 19 in intervention and 13 in
    controls cf with 2 nationally
  • Asthma patients had increased monitoring of peak
    flows and had a written action plan
  • Asthma no difference in use of long term
    controller medications

40
Clinical Outcomes
  • Heart failure improved self-management incl
    knowledge and self-management skills
  • 86 of intervention patients reported education
    re daily weighing cf 34 in control group
  • No difference in quality of life
  • Increased satisfaction with doctor by
    intervention patients

41
Rand Evaluation
  • Costs 35,000 to participate
  • 100,000 for implementation
  • Re-hospitalisation costs not assessed because of
    small no of patients, short time frame, not a
    high risk sample

42
Collaboratives Success Elements
  • Teams that met weekly
  • Successful teams averaged 45 changes
  • Successful teams had a high number of early
    change cycles
  • A culture of teamwork and growth
  • Not dependent on baseline features of CCM
  • Not dependent on wealth of the organisation

43
Collaboratives Success Elements
  • Teams with a higher proportion of doctors
  • Teams with a team champion
  • High organisational commitment to quality
    improvement
  • Contact with other teams during the collaborative
  • Emphasis on collaborative decision making with
    patients

44
Which Elements of the CCM?
  • Not enough sites to test this but
  • Meta analysis of 112 published studies found that
    each element produced improved outcomes but no
    single element was found to be either essential
    or superfluous.

45
Indian Health Service
  • National Diabetes Program
  • National standards, service accreditation
  • Self-management education modules
  • Diabetes educators
  • National registry data base
  • 5 year improvement in HbA1c

46
Indiana Chronic Disease program
  • Target group Medicaide patients low income
    individuals and families (4500 people)
  • The Model
  • Call centre
  • Case managers
  • A registry
  • The Collaborative

47
Indiana Outcome targets
  • Diabetes and cardiac At 12 months
  • 80 of all diabetic patients to have a HbA1c test
    in the last 12 months
  • 30 of all diabetic patients to have HbA1c lt7 by
    12 months
  • 60 of all cardiac patients to have
    self-management goals documented

48
Registry
  • A data base provided to all clinics for each
    doctors patients involved in the collaborative
  • Provides all pathology results from the last 12
    months
  • Evidence based recommended services for each
    condition diabetes, heart disease eg podiatry,
    HbA1c, ophthalmology etc
  • Recall and reminder system for clinic staff and
    patient
  • Provides above information on each patient and
    able to provide report for all clinic patients
    with same characteristics eg diabetes with HbA1c
    gt10

49
Indiana
  • Registry (cont)
  • Able to collect names of patients to organise
    group education, eg disease specific, lifestyle
    etc
  • Able to provide aggregated data on all patients
    involved in the collaborative

50
Call Centre
  • Care coordinators using a software program linked
    to the medicaide data base with each patients
    health status and care planning self-management
    goals
  • Care coordinators have health related
    qualification, not necessarily a clinician
  • Chosen for their telephone ability not clinical
    competence

51
Call Centre
  • Initial assessments conducted by phone
  • 15 allocated to case managers but still
    registered with the call centre
  • Care coordinators followed stepwise algorithm for
    each planned call. a form of coaching based on
    the medical and self-management goals and risk
    factors

52
Call Centre
  • Screening questions eg depression with subsequent
    questions to determine severity and risk.
  • Provide education materials and local programs
  • Summary emailed to GP with agreed follow up
    actions
  • Check back technique for patient satisfaction and
    understanding
  • Back up of case manager/GP if required

53
Case Managers
  • Community health nurses
  • Patients pre selected based on the most complex
    10 with high service use
  • Home visits full assessment of medical, social
    and psychological needs
  • Time limited 6 months
  • Communication with GP

54
Results
  • 60-80 improvement in all measures at 12 months

55
Take home lessons from Fellowship Year
  • There is evidence that chronic care can be
    implemented in diverse practices and teams using
    a collaborative approach
  • Government Policy
  • Set priorities in chronic/preventive care,
  • Set population targets for health gain and
  • Direct new resources from acute care to evidence
    based chronic care prevention and management

56
Only in Australia
57
And lastOnly In America
58
Information
  • http//www.improvingchroniccare.org
  •  
  • http//www.indianacdmprogram.com
  • www.ihi.org

59
Thank You
  • Flinders Human Behaviour and Health Research Unit
  • Malcolm.Battersby_at_flinders.edu.au
  • Ph (08) 8404 2323 Fax (08) 8404 2101
  • http//som.flinders.edu.au/FUSA/CCTU/Home.html
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