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The Chronic Care Model: An Organized Approach to Quality Chronic Illness and Other Care

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Chris Campanile MD PhD. QPRI, Clinical Coordinator. RICCC Chair ... 'The current care systems cannot do the job.' 'Trying harder will not work. ... – PowerPoint PPT presentation

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Title: The Chronic Care Model: An Organized Approach to Quality Chronic Illness and Other Care


1
The (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

2
Why is This Work Important?
  • IOM Quality Report

3
The IOM Quality Chasm ReportSelected Quotes
  • The current care systems cannot do the job.
  • Trying harder will not work.
  • Changing care systems will.

4
Other 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

5
General 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

6
Shewart/Deming CyclePlan-Do-Check-Act (PDCA)
7
Learning Model
  • Developed by IHI
  • Learning Sessions
  • Action Periods
  • Outcomes Congress

8
Why Adopt the Chronic Care Model?
  • Chronic Conditions Are Common
  • Similarities Among Chronic Conditions Afford Some
    Standardization in Care
  • CCM Has Wide Applicability

9
Model 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.

10
Essential Element of Quality Chronic Illness Care
Prepared Proactive, Practice
Team
Informed, Activated, Patient and
Family
Productive Interactions
11
Chronic Care Model
12
Additional Qualities of CCM
  • Patient-centered
  • Culturally Aware
  • Timely and Efficient
  • Evidenced-Based and Safe
  • Coordinated

13
Chronic 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
14
HCO 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

15
Broader 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

16
Chronic 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
17
DSD Concepts/Examples
  • Huddling to Prepare for the Expected
  • Front Desk / M.A. Preparation
  • Different Types of Visit
  • Care Team Members Providing These Encounters

18
Provider Team
  • MA
  • RN
  • Nutritionist
  • Mental Health Professional
  • Home Health Professional

19
Chronic Care Model
Effective information systems can measure the
success of treatments across populations and
deliver reminders about care for individuals.
3. Clinical Information Systems
20
CIS Examples
  • Traditionally, IT Support For
  • Patient Registry Function (ideally part of EHR)
  • Reporting Functionality (Performance Exception
    Reports)
  • Data-Driven Improvement!

21
More Recent CIS Examples
  • Patient History/Evaluation Software (Hows Your
    Health)
  • Patient Portal for - Scheduling
  • - Access to Health Information
  • e-Prescribing

22
Chronic Care Model
Practice teams require evidence-based protocols
to guide their decisions about patient care.
4. Decision Support
23
Decision 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

24
Chronic Care Model
Successful self-management programs rely on a
collaborative process between patients and
providers.
5. Self-Management Support
25
SM 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

26
Chronic Care Model
Health systems must take advantage of
community-based programs that enhance chronic
illness care.
6. Community Resources and Policies
27
CR 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

29
What 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

30
What 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

31
How 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

32
How 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

33
Communication 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

34
Nurse 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

35
Did I Get It Right?
  • What Do You Feel Are The Issues? Solutions?

36
Improving Chronic Illness Care
  • A national program of the
  • Robert Wood Johnson Foundation.
  • http//www.improvingchroniccare.org
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