Title: Care Model Applicability and Evidence for Planned, Proactive Care for All
1Care Model Applicability and Evidence for
Planned, Proactive Care for All
- Pat Lundgren
- Innovations in Planned Care - IHS
- Cindy Hupke
- Institute for Healthcare Improvement
2Objectives
- Define the three elements Will, Ideas, and
Execution, that are needed to achieve remarkable
breakthrough improvement. - Describe evolutionary changes made to the Chronic
Care Model over the past five years and recent
refinements made to the Care Model for the
IPC-IHS - Identify the population that we are collectively
trying to reach and the similarities to IHS
Diabetes Programs already in place - List high leverage system wide changes applicable
across all conditions and prevention - Summarize the Challenges and Successes
experienced by the participating Pilot sites in
the IPC-IHS.
3Elements needed for breakthrough improvement?
4Elements needed for breakthrough improvement?
5Chronic 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
ICIC is a national program supported by The
Robert Wood Johnson Foundation with direction and
technical assistance provided by Group Health
Cooperative's MacColl Institute for Healthcare
Innovation".
Improved Outcomes
6The expanded model The Care Model
- The Institute of Medicine report, Crossing the
Quality Chasm - Redesigning care processes and improving
coordination across conditions, services, and
settings includes more than simply achieving more
productive interactions for chronic illness or
preventive care. It also means greater office
efficiency, better access, more assured patient
safety, and the other features of high quality
care outlined in the Quality Chasm" report. - The Care Model (2003) differs from the Chronic
Care Model in two important ways - inclusion of the six aims from the Quality Chasm
report as criteria for high quality services and - addition of change concepts addressing staff
development, cultural competence, care
coordination and patient safety.
7Care Model
Health System
Community
Health Care Organization
Resources and Policies
Delivery System Design
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
- Define roles and distribute tasks among team
members - Use planned interactions to support
evidence-based care - Provide clinical case management services for
complex patients - Ensure regular follow up by the care team
- Give care that patients understand and that fits
with their cultural background
Productive Interactions
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Patient Centered
Coordinated
Timely and Efficient
Evidence-based and Safe
ICIC is a national program supported by The
Robert Wood Johnson Foundation with direction and
technical assistance provided by Group Health
Cooperative's MacColl Institute for Healthcare
Innovation".
Improved Outcomes
8Care Model IPC-IHS
Productive Interactions
Productive Interactions through effective asset
based partnering over time
Informed, Empowered Patient and Family
Patient Driven
Prepared, Proactive Practice Team
Coordinated
Timely and Efficient
Evidence-based and Safe
Improved achievement of patient and community
goals
Improved Outcomes
9Care Model
- Patient Centeredness
- Assessment of Practice
- Leadership and Sponsor Development and
Responsibility - Process Mapping for Efficiency
- Care Team
- Optimizing the Care Team
- Continuity
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Productive Interactions through effective asset
based partnering over time
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Patient Driven
Coordinated
Timely and Efficient
Evidence-based and Safe
High Leverage Early Changes
Improved achievement of patient and community
goals
Developed by the MacColl Institute and adpated by
IHS for the CCI
Wagner EH. Chronic disease management What will
it take to improve care for chronic illness?
Effective Clinical Practice. 199812-4
10Indian Health Diabetes Best Practices
11Indian Health Diabetes Best Practices and IPC-IHS
12DV/IPV 8 Steps
- Create a multi-disciplinary team which may
include physician, nurse, soc. worker, BH
providers, and local DV advocate - Complete an assessment of your practice (response
to DV, PP, GPRA scores, etc.) - Develop screening process
- Develop and/or revise policies and procedures so
that the process is easily understood and
reliable moving forward. - Train your staff to build capacity within your
organization - Get the message out to the community about the
importance of the problem and approaches - Support employees who have experienced DV/IPV
- Use data to drive improvement. Collect data on
measures, plan and do the changes, study the
results, and make subsequent changes.
13Others include
- Behavioral health
- Tobacco screening and programs to quit
- Cardiovascular programs and approaches
- Cancer
- Prevention
- Public Health and CHRs
14Patients with Diabetes and other Chronic
Conditions
Patients with Diabetes and Preventive Services
Needs
Patients with Diabetes
Patients at Risk Obesity, Sedentary, Family
History of Chronic Conditions, Environment, Etc.
Patients Needing Safe, Timely, Effective,
Efficient, Equitable, and Patient Centered Care
15A Sample of Changes Being Tested, Implemented,
and Spread across IPC-IHS Sites
- Empanelling
- Care team
- Use data to drive improvement
- Optimize use of HIT
- Remove waste
- Plan for every pt
- Segment care
- Reminders system
- Move work to appropriate licensure
- Reliable follow-up
- Max packing
- Proactive care across spectrum
- Self-Management
- Huddles
- Integration into community
- BH integrated into PC
- Building QI capacity in workforce
- Transportation for pts
- Integration of traditional medicine
- Guidelines of care
- Advanced access
16Current Sequencing
- Emphasize the patients central role in
- managing their health
- Effective self-management support strategies
- Ensure regular follow-up by the team
- Provide timely automated reminders
- Build the business case
Phase 3
Phase 2
- Process flow mapping to reduce waste and increase
efficiencies - Clinical Information System (CIS) development
- Determining community needs and wants
- Cultural focus
- Use of data to drive improvement
Phase 1
- Assessments-Green Book
- Leadership engagement and involvement
- Continuity with Provider and Care team
- Building improvement capacity in staff
- Identification and optimization of care team
- Community engagement
1710 Steps involved in some early successes(not in
any specific sequence, yet)
- Assessments-Green Book
- Leadership engagement and involvement
- Determining community needs and wants
- Building improvement capacity in staff
- Continuity with Provider and Care team
- Identification and optimization of care team
- Process flow mapping to reduce waste and increase
efficiencies - Use of data to drive improvement
- Clinical Information System (CIS) development and
use - Reporting regularly
18Challenges
- Access
- Delays and waits
- Continuity with provider
- Lack of care team
- Communication
- Distance and transportation
- Tribal, Federal, Urban
- Costs
- Recruitment and retention of staff
- Traditional and Western Medicine
- We would like to see a system where traditional
and western practices work alongside one another
(Gallup Sundancer and Psychiatrist, Dr.
Laughter)
19Successes
- Increasing continuity
- Care team development and communication
- Staff working to the highest level of their
licensure - Work force development and capacity building
relating to improvement work - Understanding how to use data to drive
improvement daily - Improved access to care
- Timely management of chronic care and preventive
services - Less dependence on urgent care and emergency
visits - Proactive care for patients
- Reduction in hospitalizations
20Intake Bundle
Cancer Screening Bundle
BP in Control
Goal
Goal
Goal
3rd Next Available
DM Comprehensive
Office Visit Cycle Time
Goal
Goal45
Goal3
21Hungry for more!
- Advanced access
- Group visits
- Understanding what the patient and community
needs and wants and when they need and want it! - Efficiencies and waste reduction
- Using the clinical information system and data to
drive improvement and practice proactive
population management - The business case for this work
22Sequencing
Early Stages
Status Quo
Uncharted Territory
Change Package
Results
Under Construction
23Questions?