Chronic Care Management

Sherri Homan RN, PhDMissouri Department of Health and Senior ServicesOffice of EpidemiologyJefferson City, MO

Chronic Care Management Design

Pioneered by Edward H. Wagner, MD, MPH and colleagues at MacColl Institute for Healthcare Innovation at Group Health Cooperative of Puget Sound, Seattle Washington*

Supported by Robert Wood Johnson Foundation**

*Wagner, E.H. (1998). Chronic disease management. What will it take to improve care for chronic illness? Effective Clinical Practice, 1, 2-4.

**Improving Chronic illness Care (ICIC) is a national program supported by Robert Wood Johnson Foundation with direction and technical assistance by Group Health Cooperative’s MacColl Institute for Healthcare Innovation.

Chronic Care Management Premise

Right Thing

Right Patient

Right Time

Chronic Care Management Model

3. Self-Management Support

4. Delivery 5. Decision 6. Clinical System Support Information Design Systems

2. Health SystemHealth Care Organization

1. CommunityResources and Policies

Informed,ActivatedPatient

Prepared, ProactivePractice Team

Productive Interactions

ImprovedOutcomes

Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice 1998; 1:2-4. Permission to reproduce model image granted from American College of Physicians (ACP), July 7, 2006.

Mobilize Community Resources

Patients participate in effective community programs

Form partnerships to fill gaps in needed services and avoid duplicating efforts

Advocate for policies to improve patient care

Health System – Organization of Care

Improvement at all levels of the organization

Promote effective strategies Open and systematic

handling of errors and quality issues to improve care

Provide incentives based on quality of care

Facilitate care coordination within and across organizations

Self-Management Support

Patient has a central role in managing health

Self-management support strategies

– Assessment, goal-setting, action planning, problem solving, and follow-up

Community resources to support self-management

Delivery System Design

Define roles and distribute task

Planned interactions for evidence-based care

Clinical case management services for complex patients

Regular provider initiated follow-up

Cultural sensitive care

Decision Support

Daily practice of evidence-based care

Share clinical guidelines and information with patients*

Provide professional education

Integrate specialty and primary care

*Agency for Healthcare Research and Quality – National Guideline Clearinghousehttp://www.guideline.gov

Clinical Information Systems

Timely reminders for providers and patients

Identify subpopulations for proactive care

Facilitate individual patient care planning

Share information Monitor outcomes

Continuous Quality Improvement

Registry

tracks

individuals and populations

Chronic Care Management Programs

Comprehensive system change

Targeting

Case management

Primary Care Delivery System

Traditional Provide acute care Diagnostic and laboratory

services Treatment of signs and

symptoms Prescriptions Brief education Short appointments Patient-initiated follow-up

Delivery System Redesign

Traditional Provide acute care Diagnostic and

laboratory Services Treatment of signs and

symptoms Prescriptions Brief education Short appointments Patient-initiated follow-

up

Reconfigured Developed processes for CD Incentives for making

changes Extensive patient education

to increase patient’s confidence and skills

Provider-initiated appointments and follow-up

Evidence-based guidelines and provider interaction

Information Systems

Targeting Approach

Correctly assumes a small percent of the population accounts for most health care costs

Possible to reduce cost based on this method

However, health status changes occur frequently

“Targeting” misses a substantial portion of the population at risk

Case Management Approach

Many programs include: Brief hospitalization Low intensity follow-up

care Conduct utilization

review

Chronic Care Management advocates for:

Access to services that are

proven to improve outcomes

Examples: Missouri’s Chronic Health Care Indicators, BRFSS, 2004

69.1% of seniors (age 65+) received a flu shot in past 12 months

65.2% of adults with diabetes test their blood sugar at least once daily

55.6% of adults with diabetes have participated in a course or class to manage their diabetes

52.8% of adults (age 50+) have ever had a lower endoscopy exam

39.9% of adults with arthritis have received a suggestion from their health care provider to exercise or engage in physical activity to help their joint symptoms (2003)

Example: Medicaid

A web-based system to help fee-for-service Medicaid patients manage chronic conditions

Integrate APS Healthcare’s CareConnection application with a chronic care improvement program

Product – “collaborative medical record”

Accessible to patients, providers and health care coaches

The Advisory Board Company. (2006) Missouri creates web-based chronic care system. iHealth Beat. Retrieved June 20, 2006 from http://www.ihealthbeat.org

Incentives

Vary across provider organization

May reduce patient expenses

May also reduce profitable inpatient care

Poorly reimbursed preventive services

Performance related to defined quality goals

Providers - / +

Provider groups with full-capitation +

Health Plans (deliver returns within 6-12 mo) ++

Purchasers / Employers +++

Governmental entities ++++

+ greater incentive to engage in disease management

Primary Care Physician Use of Electronic Medical Records

Country Percent Using EMR

Sweden 90%

Netherlands 88%

Britain 58%

Finland 56%

Austria 55%

Germany 48%

Belgium 42%

Italy 37%

Ireland 28%

Greece 17%

U.S. 17%

Spain 9%

France 6%

Portugal 5%

Source: Harris Interactive Inc. (2002, August 8). European physicians especially in Sweden, Netherlands and Denmark, lead U.S. in use of electronic medical records. HealthCare News, 2(16), 1-3.

European Union Barometer June, July 2001 (numbers repercentaged by Harris Interactive) and Harris Interactive Surveys for U.S.A. in June 2001 and January / February 2001.

EuroBarometer survey (N = 3,504)

U.S.A. survey (N = 377)

Care Management Processes in Physician Organizations (N = 1,040)

Process Diabetes Asthma CHF

1. Case management 39.7 39.7 43.4

2. Feedback to physicians

24.1 24.1 30.5

3. Disease registries 31.2 31.2 34.8

4. Clinical guidelines with reminders

33.9 33.9 27.7

Mean 33.2 32.2 34.1

Practices using all 4 12.7 7.6% 8.6

Casalino, L. et al. (2003). External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Journal of the American Medical Association.

Chronic Care Management

Regular visits with health providers

Focus on function Prevent exacerbations and

complications Emphasizes self-management Ensures access to services

proven to improve outcomes Establishes links through time

with information systems Follow-up initiated by medical

provider

Improved Health StatusOverarching Goal

In Summary

Chronic care management offers improved health status for many with chronic diseases

Chronic illness care should be based on the best available evidence

Need consistent quality measures and additional research in the various models