Title: The Chronic Care Model: An Organized Approach to Quality Chronic Illness and Other Care
1The (Chronic) Care ModelAn Organized Approach
to Quality Chronic Illness and Other Care
- Chris Campanile MD PhD
- QPRI, Clinical Coordinator
- RICCC Chair
- Hillside Ave. Family Community Medicine
- June 4, 2008
2Why is This Work Important?
3The IOM Quality Chasm ReportSelected Quotes
- The current care systems cannot do the job.
- Trying harder will not work.
- Changing care systems will.
4Other Reasons Why This Is Work Important?
- Evidence says we can improves pt. outcomes
- You Cant Improve What You Dont Measure
- Becoming known as the _____ of choice
- Economic rewards for superior performance
5General Concepts
- Address work PROCESSES
- Think Large Your Whole System of Care Will
Probably Need Modification - Adopt a Model for Improvement
- Team Must Include a Member to do the Registry
Maintenance/Reporting and Patient Contact Work
6Shewart/Deming CyclePlan-Do-Check-Act (PDCA)
7Learning Model
- Developed by IHI
- Learning Sessions
- Action Periods
- Outcomes Congress
8Why Adopt the Chronic Care Model?
- Chronic Conditions Are Common
- Similarities Among Chronic Conditions Afford Some
Standardization in Care - CCM Has Wide Applicability
9Model Development 1993 --
- Initial experience at GHC
- Literature review
- RWJF Chronic Illness Meeting -- Seattle
- Review and revision by advisory committee of 40
members (32 active participants) - Interviews with 72 nominated best practices,
site visits to selected group - Model applied to diabetes, depression, asthma,
CHF, CVD, arthritis, and geriatrics - Main author of Model Edward H. Wagner, MD, MPH,
FACP, National Program Director, Improving
Chronic Illness Care.
10Essential Element of Quality Chronic Illness Care
Prepared Proactive, Practice
Team
Informed, Activated, Patient and
Family
Productive Interactions
11Chronic Care Model
12Additional Qualities of CCM
- Patient-centered
- Culturally Aware
- Timely and Efficient
- Evidenced-Based and Safe
- Coordinated
13Chronic Care Model
Better care means not only identifying best
practices, but creating policies and
organizations that allow such practices to
flourish.
1. Health System - Organization of Health Care
14HCO Examples
- Senior Leader Buy-in
- Whats Important to SL?
- Collaborate on That
- Show Progress to All Stakeholders
- Share Reimbursement and Recognition
- Bring Chronic Illness Care to a More Prominent
Position
15Broader Definition of the Health Care Organization
- Traditionally within the 4 walls
- Now consider to include
- Health Plans that Support this Work
- Other Providers/Agencies Outside the Ambulatory
Site, e.g, Home Health Nurses
16Chronic Care Model
Effective chronic illness management requires
more than simply adding interventions to an
existing system focused on acute care. Basic
changes in delivery system design are required
for effective care management.
2. Delivery System Design
17DSD Concepts/Examples
- Huddling to Prepare for the Expected
- Front Desk / M.A. Preparation
- Different Types of Visit
- Care Team Members Providing These Encounters
18Provider Team
- MA
- RN
- Nutritionist
- Mental Health Professional
- Home Health Professional
19Chronic Care Model
Effective information systems can measure the
success of treatments across populations and
deliver reminders about care for individuals.
3. Clinical Information Systems
20CIS Examples
- Traditionally, IT Support For
- Patient Registry Function (ideally part of EHR)
- Reporting Functionality (Performance Exception
Reports) - Data-Driven Improvement!
21More Recent CIS Examples
- Patient History/Evaluation Software (Hows Your
Health) - Patient Portal for - Scheduling
- - Access to Health Information
- e-Prescribing
22Chronic Care Model
Practice teams require evidence-based protocols
to guide their decisions about patient care.
4. Decision Support
23Decision Support Examples
- Distribution of Annual ADA Guideline Updates
- Forming Stronger Working Relationship with
Specialists - Attending Conferences / Inviting Speakers to
Ensure Aware of Up-To-Date Information
24Chronic Care Model
Successful self-management programs rely on a
collaborative process between patients and
providers.
5. Self-Management Support
25SM Support
- MD Realization That Needs Help With This
- Utilizing Team Members to Assist (MA, RD, CDOE,
RN, Mental Health) - Home Health Well Positioned to Provide SMS
26Chronic Care Model
Health systems must take advantage of
community-based programs that enhance chronic
illness care.
6. Community Resources and Policies
27CR Examples
- Hillside
- Spanish-speaking Mental Health
- CV RNs at Saranna Home Care
- East Bay CHC, Newport
- Pt. Assistance Programs for Medications, Testing
Supplies, Lab Work, Eye Care
28- How Can Home Health Providers Leverage the CCM to
- Improve Patient Outcomes
29What Advantages to HH Professionals Have?
- Provide Care in the Patients Home Environment
- Provide Care in the Context of the Family
- Obtain a Truer Sense of Patients Function
- Have More Time Than Typical Office Encounter to
Interact with Patients
30What Disadvantages Create Barriers for HH
Professionals
- Are not seen as equivalent to on-site health care
team members - Care of the patient is temporary
- Dont have access to the medical record
- Access to PCP can be difficult
31How Can the CCM Help?
- Enlist senior leader support for resources to
address problems (HCO) - Become appropriately expert in common chronic
illnesses (DS) - Become skilled in SMS
32How Can the CCM Help?
- Become aware of patients cultural beliefs as
they pertain to health care - Become aware of community resources that are
appropriate for your patients - Survey patients re satisfaction (as just done)
and respond to areas needing improvement - Track, Report, Innovate around issues that need
improving
33Communication with PCP
- Love / Hate relationship (reimbursement issue?)
- Be succinct in style
- Survey Drs. re when and how they would like to
communicate with? (help from Med. Dir.?) - Ideally, could email via the office EHR
- Possibly regular email is OK
- Probably awaits functioning HIE
34Nurse Care Manager
- Hub of the Care Team
- Provides Direct Services (dz. education,
mediation review, SMS) - Provides connection to needed resources which
exist in the community - The HH RN as a NCM
35Did I Get It Right?
- What Do You Feel Are The Issues? Solutions?
36Improving Chronic Illness Care
-
- A national program of the
- Robert Wood Johnson Foundation.
- http//www.improvingchroniccare.org