The Chronic Care Model

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The Chronic Care Model

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• Developed by Ed Wagner, MD, MPH and colleagues
• MacColl Institute for Healthcare Innovation
• Group Health Cooperative of Puget Sound
• home of the
• Robert Wood Johnson Foundation National Program,
• Improving Chronic Illness Care

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The IOM Quality reportA New Health system for
the 21st Century
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The IOM Quality reportA New Health system for
the 21st Century

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

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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
• 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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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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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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Chronic Care Model Development 1993 --

• Initial experience at GHC
• Literature review
• RWJF Chronic Illness Meeting -- Seattle
• Review and revision by advisory committee (40
  members (32 active participants)
• Interviews and site visits with 72 nominated
  best practices
• Model applied with diabetes, geriatrics, asthma,
  CHF, and depression with over 200 health care
  organizations

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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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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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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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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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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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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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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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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