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Care Model Applicability and Evidence for Planned, Proactive Care for All

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Redesigning care processes and improving coordination across conditions, ... Chronic disease management: What will it take to improve care for chronic illness? ... – PowerPoint PPT presentation

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Title: Care Model Applicability and Evidence for Planned, Proactive Care for All


1
Care Model Applicability and Evidence for
Planned, Proactive Care for All
  • Pat Lundgren
  • Innovations in Planned Care - IHS
  • Cindy Hupke
  • Institute for Healthcare Improvement

2
Objectives
  • 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.

3
Elements needed for breakthrough improvement?
  • Will
  • Ideas
  • Execution

4
Elements needed for breakthrough improvement?
  • Will
  • Ideas
  • Execution

5
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
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
6
The 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.

7
Care 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
8
Care 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
9
Care 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
10
Indian Health Diabetes Best Practices
11
Indian Health Diabetes Best Practices and IPC-IHS
12
DV/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.

13
Others include
  • Behavioral health
  • Tobacco screening and programs to quit
  • Cardiovascular programs and approaches
  • Cancer
  • Prevention
  • Public Health and CHRs

14
Patients 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
15
A 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

16
Current 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

17
10 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

18
Challenges
  • 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)

19
Successes
  • 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

20
Intake Bundle
Cancer Screening Bundle
BP in Control
Goal
Goal
Goal
3rd Next Available
DM Comprehensive
Office Visit Cycle Time
Goal
Goal45
Goal3
21
Hungry 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

22
Sequencing
Early Stages
Status Quo
Uncharted Territory
Change Package
Results
Under Construction
23
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