Chronic Care Model by xV43uA2v


Diabetes, Obesity, Cardiovascular
        Presentation Title
      “DOC” Collaborative

   The Chronic Care Model:
   A Framework to Improve
        Diabetes Care
       Lisa Letourneau MD, MPH
 Describe model for improving chronic
  illness care and prevention that is…
  – Patient-centered
  – Interdisciplinary
  – Evidence-based
 Demonstrate how Chronic Care Model can
  provide an effective framework for
  practices to improve diabetes care
Why Change? Meet Ms. D.
 56 yr old mother, wife, &
 Seen by PCP 4X/ in past
  6mos - multiple complaints
 Sx: fatigue, non-specific sx
 PE: Wgt 180, BP 145/92,
  no other abnl findings
 Initial dx stress,
The Story of Ms. D…
           On 3rd visit, fasting
            blood sugar 145: told
            “borderline” diabetes
           Advised to “watch diet,
            lose weight”
           Follow up suggested in
            one year
 The Story of Ms. D…
 1 yr later: Wgt 187, BP 150/90;
  Fasting blood sugar 165
 PCP prescribes metformin
 Doesn’t pick up meds (too
 6 mos later: seen by coverage for
  blurred vision, headaches
 Unable to work for past X2 wks
 Blood sugar 450…
Atypical or Too-familiar Story?
“Usual” chronic illness care…
 Oriented to acute illness
 Focus on symptoms, tests, lab results
 Geared towards physician’s treatment,
  not patient’s role in management
 Interaction frustrating for patient, doctor
 Incentives favor “expeditious resolution”,
  not targeted outcomes
Current “Systems”
The Watchword

 “Systems are perfectly
  designed to get the
  results they achieve”
         -Paul Batalden
 The Results We are Achieving…
 Saddine 2002: charts of 4000+ patients
  – 18% poor HbA1c control (>9.5)
  – 34% BP >140/90
  – 68% LDL >130
  – 37% no evidence dilated eye exam in prior yr
  – 45% no evidence of foot exam in prior year

   Saaddine et al., Ann Int Med Apr 2002
Why the Gaps?
 “Tyranny of the urgent”!
 Increased demands for time, attention
  in PCP setting
 Current system does not support,
  reward better population-based
 Need a different system of care!
Essential Elements of Good
   Chronic Illness Care
 Informed,    Productive    Prepared
 Activated                  Practice
 Patient                    Team

What Characterizes an
“Informed, Activated” Patient?
Patient…            Patient
  • understands the disease process
  • realizes his/her role as the daily self manager
Family and caregiver…
  • are engaged in patient’s self-management
The provider is viewed ..
  • as a guide on the side, not “the sage on the
What Characterizes a “Prepared”
Practice Team?             Prepared
At the time of the visit, the care
team has…
• patient information
• decision support
• people, equipment, and time
… required to deliver evidence-based
clinical management and self-
management support
           Chronic Care Model

                              Health System
Resources and Policies Health Care Organization
               Self-    Delivery                  Clinical
           Management System        Decision
             Support                Support
                         Design                  Systems

        Informed,     Productive      Prepared,
        Activated                     Proactive
                     Interactions     Practice Team

                Improved Outcomes
The Chronic Care Model in Action
    TARGET Diabetes Program
      Chronic Care Model for Diabetes
     Community                  Health System
Resources and Policies       Health Care Organization
         Patient & Family        Delivery                Clinical
        Education & Self-                   Decision
                                 System     Support    Information
       Management Support        Design                 Systems

 Support patient’s ability to understand, manage their diabetes
• Use standard, basic patient education materials (consistent
• Encourage referrals for formal diabetes education
• Promote use of diabetes self-care tools (TARGET self-care report,
  goal setting tools)
• Practice collaborative goal setting, problem-solving (vs.seeking
Self-management Support
  – Use standardized patient ed materials, tools – e.g
    TARGET self-care cards, educational booklets
  – Focus on collaborative self-management goals
Moving beyond “compliance”…
   Think differently!
   Focus on collaborative goal
    setting with patients
   Effectively support behavior    “Non-compliance”
    change with patients:
    1. Do you want to make a
    2. How are you going to make
       the change?
    3. What can I do to help you?
The informed patient is part of the “team” in
this new model of “delivery system redesign”
        Chronic Care Model for Diabetes
                                           Health System
    Resources and Policies        Health Care Organization
         Education & Self-        Delivery      Decision      Clinical
        Management Support                      Support    Information

                       Know who’s on your team!
•    Identify, build care team (including local diabetes educator) –
    need to identify, value explicit roles for all team members
•   Use planned diabetes visits (can’t rely solely on acute care visits)
•   Provide follow-up care according to guideline recommendations
•   Consider alternative care models – e.g. group visits, follow-up
    phone calls
      Delivery system redesign:
Every member of the team has a role!
     Chronic Care Model for Diabetes
                                 Health System
 Resources and Policies       Health Care Organization

                                 Delivery   Decision     Clinical
            Education & Self-
                                 System     Support    Information
           Management Support
                                 Design                 Systems

           Translate guidelines into practice!
• Use evidence-based guidelines (ADA Standards) to drive care
• Embed guidelines in practical tools, algorithms – e.g.
    - Diabetes flow sheet; BP/glycemic control algorithms
• Encourage case-based learning, alternative models for provider
• Access, integrate specialist expertise when needed
        Decision Support Tools:
Algorithms, guidelines, and flowsheets
     promote consistency of care
       Chronic Care Model for Diabetes
                                    Health System
   Resources and Policies        Health Care Organization

                                   Delivery   Decision
              Education & Self-                          Information
                                   System     Support
             Management Support
                                   Design                  Systems

Use data to improve health of individuals and populations!
• Use diabetes registry to identify patient populations, track key
  diabetes, CVD outcomes
• Use registry progress reports to monitor performance, provide data
• Identify high-risk pt subgroups needing proactive care – e.g.
     - HbA1C>9%; pt’s without visit in past 12 mos; needing labs
Using registry as a tool to
 support proactive care
    Chronic Care Model for Diabetes
 Community                               Health System
 and Policies                        Health Care Organization

                Education & Self-        Delivery      Decision         Clinical
                  Management             System        Support        Information
                    Support              Design                        Systems

• Develop partnerships with Maine Diabetes Prevention & Control
  Program, local DSME programs, ADA,
• Become aware of, link with community educational resources
• Strengthen connections with local Healthy Maine Partnerships
• Partner with workplaces, schools, faith communities
• Raise public awareness through community education, PSA’s

      Adapted from Homer C., National Initiative for Children’s Health Care Quality
But Does It Work???
Diabetes Collaboratives 1 & 2
                 Ask them!!
Advantages of General
System Change Model
  Applicable to most chronic care issues
  Once system changes in place,
   accommodating new guideline or
   innovation much easier
  Focus is on improving system, not
   finding fault with individuals
  Can be readily adapted for improving
   preventive care
Ms. D. Revisited
          Hears local “pre-diabetes” PSA
          Takes ADA “Risk Test”; books
           PCP visit; FBS ordered pre-visit
          PCP dx’s Type 2 diabetes, offers
           “TARGET Diabetes Info” booklet,
           sched’s follow up visit in 2 wks
          Follow up visit: HbA1c 8.8%;
           results recorded w/ pt; referred
           for diabetes education
 Ms. D revisited…
 Pt attends ADEF classes, sets
  self-management goal
 Starts local walking program,
  takes grocery store tour
 PCP f/u visit at 1 mo: Starts oral
  meds (covered by health plan)
 Nurse calls Ms. D. 2 wks later –
  answers questions about med
  side effects, encourages f/u visit
Ms. D. – A Better Ending…
 Ms. B able to continue working;
  husband, kids notice significant
 HA’s, fatigue diminishing
 Follow up PCP visit at 8 wks: sx
  much improved, HbA1c 8.1%
 Plan to continue meds, taper
  care manager calls, f/u in 2 mos
For more info:

 • Chronic Care Model references

 Adapted from presentation by Ed Wagner M.D,
MPH, Macoll Institute, Group Health Puget Sound

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