Download Chronic Care Model Interactive Module

The Chronic Care Model
Improving Care for People Living
with HIV and AIDS
© 2004 Institute for Healthcare Improvement
Objectives
Define the problem in today’s health care
systems
State five useful aims to keep in mind while
seeking to improve care
Describe the development of the Chronic
Care Model (CCM)
List the six components of the CCM
Apply the CCM to improving care for
people living with HIV and AIDS
© 2004 Institute for Healthcare Improvement
Defining the Problem
Selected quotes from the Institute of
Medicine (IOM) quality report:
“The current care systems cannot do the
job”
“Trying harder will not work”
“Changing care systems will”
Source: IOM “Crossing the Quality Chasm: A New
Health System for the 21st Century” (2001)
© 2004 Institute for Healthcare Improvement
IOM Report: Six Aims for
Improving Health Systems
Safe: avoids injuries
Effective: relies on scientific knowledge
Patient-centered: responsive to patient
needs, values, and preferences
Timely: avoids delays
Efficient: avoids waste
Equitable: quality unrelated to
personal characteristics
© 2004 Institute for Healthcare Improvement
IOM Rules for Care
1. Base care on continuous healing
relationships
2. Customize care to patient needs
and values
3. Patient is the source of control
Source: IOM “Crossing the Quality Chasm: A New
Health System for the 21st Century” (2001)
© 2004 Institute for Healthcare Improvement
IOM Rules for Care
4. Knowledge is shared and information
flows freely
5. Use evidence-based decision
making
6. Safety is a system property
Source: IOM “Crossing the Quality Chasm: A New Health System for the
21st Century” (2001)
© 2004 Institute for Healthcare Improvement
IOM Rules for Care
7. Transparency is necessary
8. Anticipate patient needs
9. Decrease waste continuously
10. Cooperation among clinicians is a priority
Source: IOM “Crossing the Quality Chasm: A New
Health System for the 21st Century” (2001)
© 2004 Institute for Healthcare Improvement
The Chronic Care Model
MacColl Institute for Healthcare Innovation
Group Health Cooperative (GHC)
Improving Chronic Illness Care
A National Program of
The Robert Wood Johnson Foundation (RWJF)
Ed Wagner, MD
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Development (1993)
Initial experience at GHC
Literature review
RWJF chronic illness meeting -- Seattle
© 2004 Institute for Healthcare Improvement
Model Development
Review/revision by advisory committee
Interviews and site visits with 72
nominated “best practices”
Model applied with diabetes, geriatrics,
asthma, CHF, CVD, HIV/AIDS, and
depression with over 500 health care
organizations
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Health System
Community
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Health Care Organization
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Essential Elements of Good
Chronic Illness Care
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
© 2004 Institute for Healthcare Improvement
Prepared Practice Team
Has the:
Patient information
Decision support
People
Equipment
Time
To deliver:
Evidence-based clinical management
Self-management support
© 2004 Institute for Healthcare Improvement
Informed, Activated, Patient
Patient understands the disease process
and realizes his/her role as the daily selfmanager
Family and caregivers are engaged in the
patient’s self-management
The provider is viewed as a guide on the
side, not the sage on the stage!
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Health System
Community
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Community
Linkages and partnerships lead to:
Successful programs
Coordinated guidelines
and measures
Policies that support
patients
© 2004 Institute for Healthcare Improvement
Change Ideas: Community
Create a consumer advisory board (CAB)
Create and maintain updated list of
community resources and ensure
distribution to staff, patients, and families
Raise community awareness through
networking, outreach, and education
© 2004 Institute for Healthcare Improvement
Change Ideas: Community
Establish linkages and connections to care
within/across organizations to develop
programs/policies, referral opportunities.
Identify and remedy current gaps in
community resources.
© 2004 Institute for Healthcare Improvement
Pairs Discussion
(10 minutes)
With a partner, discuss in what ways you
are/could be improving linkages and
partnerships between the community and
the health system. (3-4 minutes)
Next, turn to a pair next to you, and share
the highlights of both discussions. (3-4 minutes)
Last, be prepared to tell the large group one
highlight of these discussions. (2 minutes)
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Organization of Health Care
Creating an environment for improvement
efforts to flourish:
 Coherent approach to system improvement
 Leadership committed to and responsible for
clinical outcomes
 Incentives to providers and
patients to improve care and
adhere to guidelines
© 2004 Institute for Healthcare Improvement
Change Ideas:
Organization of Health Care
Assure senior and clinical leaders visibly
support/promote efforts to improve
HIV/AIDS care by removing barriers and
providing necessary resources
Assign accountability for continued clinical
improvement at all levels of the
organization
© 2004 Institute for Healthcare Improvement
Change Ideas:
Organization of Health Care
Make improving HIV/AIDS care a part of
the organization’s vision and mission,
goals, performance improvement, and
business plans
Integrate models into the “fabric” of the
organization
© 2004 Institute for Healthcare Improvement
Case Study
(15 minutes)
Your HIV/AIDS Disease Clinic leadership
wants to make the clinic a “Center for
Excellence.” Using the ideas in the
“Organization of the Health System,” what
are five important “first steps” for the
leadership to pursue?
Discuss this in your small groups for about
10 minutes. Then be prepared to share your
ideas with the large group.
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Health System
Community
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Improved
Outcomes
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
© 2004 Institute for Healthcare Improvement
Self-Management and Adherence
People living with HIV disease need:
 Basic information about disease and treatment
 Understanding of/assistance with selfmanagement skill building
 Ongoing support from clinic team, family,
friends, and community
© 2004 Institute for Healthcare Improvement
Self-Management and Adherence
Includes activities such as:
 Taking medication at proper dose and
frequency
 Communication with care team, family
 Ongoing problem solving
© 2004 Institute for Healthcare Improvement
Self-Management and Adherence
Activities continued …
 Collaborative goal setting
 Monitoring of symptoms/side effects
 Lifestyle changes
© 2004 Institute for Healthcare Improvement
What Is Self-Management?
“It means acknowledging the patients' central role in their care,
one that fosters a sense of responsibility for their own health.
It includes the use of proven programs that provide basic
information, emotional support, and strategies for living with
chronic illness. But self-management support can't begin and
end with a class.
Using a collaborative approach, providers and patients work
together to define problems, set priorities, establish goals,
create treatment plans and solve problems along the way.”
Source: Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative
management of chronic illness. Annals of Internal Medicine. 1997;127(12):10971102.
© 2004 Institute for Healthcare Improvement
What Self-Management Support
Is Not
Didactic patient education ALONE
Scolding
Solving every patient social, emotional, or
behavioral problem
Waiting for patients to ask for help
© 2004 Institute for Healthcare Improvement
The Six A’s
1. Activate: patients to take control
2. Assess: beliefs, behaviors, knowledge,
severity
3. Advise: about risks and benefits of
change
Source: Glasgow RE, Funnell MM, Bonomi AE, Davis C,
Beckham V, Wagner EH. Self-management aspects of the
improving chronic illness care breakthrough series:
implementation with diabetes and heart failure teams. Annals of
Behavioral Medicine. 2002 Spring;24(2):80-87.
© 2004 Institute for Healthcare Improvement
The Six A’s
4. Agree: with the patient on goals for
change
5. Assist: by identifying barriers and
problem solving
6. Arrange: access to additional resources,
follow-up, and flow of information
Source: Glasgow RE, Funnell MM, Bonomi AE, Davis C,
Beckham V, Wagner EH. Self-management aspects of the
improving chronic illness care breakthrough series:
implementation with diabetes and heart failure teams. Annals of
Behavioral Medicine. 2002 Spring;24(2):80-87.
© 2004 Institute for Healthcare Improvement
Change Ideas:
Self-Management Support
Train providers and other staff on how to
help patients with self-management goals
Set and document self-management goals
collaboratively with patients
Tap community resources to achieve selfmanagement goals
© 2004 Institute for Healthcare Improvement
Change Ideas:
Self-Management Support
Use planned visits in the individual and
group setting to support self-management
Follow up and monitor self-management
goals
© 2004 Institute for Healthcare Improvement
Personal Action Plan
1. Something you WANT to do
2. Describe:





How
Where
What
When
Frequency
© 2004 Institute for Healthcare Improvement
Personal Action Plan
3.
4.
5.
6.
Barriers
Plans to overcome barriers
Confidence rating (1-10)
Follow-up plan
From Kate Lorig, Chronic Disease Self-management program: Lorig K,
Holman, H, Sobel D et al Living a Healthy Life with Chronic Conditions 2
ed, Palo Alto, Bull publishing, 2001
© 2004 Institute for Healthcare Improvement
Confidence Ruler
1 2 3 4 5 6 7
8 9 10
Not
Unsure
Somewhat
Very
Confident
Confident
Confident
© 2004 Institute for Healthcare Improvement
Role Play
(20 minutes)
 Divide into groups of three. One person plays the
role of patient, another the role of caregiver, and
the third the role of observer.
 Role play the following situation: The caregiver and
patient are involved in a self-management goal
setting encounter. The topic is “starting an exercise
program.”
 After the observer critiques the role play, change
roles, and do it once more.
 Be prepared to tell the group what you learned as a
result of doing this exercise.
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Health System
Community
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Delivery System Design
Making basic changes in care delivery:
 Emphasis shifts to planned vs. acute visits
 Expansion of staff member roles and
responsibilities
 Timely access to key clinical data
 Emphasis on continuity and
integration
© 2004 Institute for Healthcare Improvement
Change Ideas:
Delivery System Design
Describe and document the new delivery
system design
Assign roles, duties, and responsibilities for
all tasks, especially for planned visits to a
multidisciplinary care team
Educate patients about delivery system
design
© 2004 Institute for Healthcare Improvement
Change Ideas:
Delivery System Design
Use the registry to proactively review care
and plan visits
Include planned visits in the individual and
group setting in the care delivery model
Make designated staff responsible for
follow-up by various methods,
including outreach workers,
telephone calls, and home visits
© 2004 Institute for Healthcare Improvement
Table Discussion
(20 minutes)
 Address these two items in a small group:
1. Identify key processes that need to be changed
or you have changed. Some examples are: noshows, follow-up, refills, self-management, lab
results. What has worked/would work?
2. How would you begin doing planned visits?
What steps are essential to begin? What roles
are critical?
 Be ready to share your thoughts on one of
the above with the large group.
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Health System
Community
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Decision Support
Implement current guidelines
 Protocols
 Flowsheets
 Training and education
 Reminders
 Progress notes
 Access to experts
© 2004 Institute for Healthcare Improvement
Change Ideas: Decision Support
Provide feedback to providers on their use
of care guidelines
Educate patients about
guidelines
Establish linkages with key specialists to
assure that primary care providers have
access to expert support
© 2004 Institute for Healthcare Improvement
Change Ideas: Decision Support
Incorporate all staff into decision support
Provide continuous skill-oriented interactive
training programs for all staff to update
knowledge of current guidelines
Embed current guidelines in the care
delivery system
© 2004 Institute for Healthcare Improvement
Best Practices
(10 minutes)
With a partner, discuss in what ways you
are/could be improving linkages decision
support. (3-4 minutes)
Next, turn to a pair next to you, and share
the highlights of both discussions. (3-4 minutes)
Last, be prepared to tell the large group one
highlight of these discussions. (2 minutes)
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Clinical Information System
Provide useful information to providers:
 Recommended services
 Key outcome measures
 Patient contact/demographic information
 Patient encounter history
 Case management updates
© 2004 Institute for Healthcare Improvement
Change Ideas:
Clinical Information System
Establish a registry
Develop an information
infrastructure (in addition to the registry)
Allocate resources for computer hardware
and software, establishing and maintaining
technical support, and personnel to support
and maintain the registry
© 2004 Institute for Healthcare Improvement
Change Ideas:
Clinical Information System
Use the registry to provide feedback to care
team and leaders
Develop processes for use of the registry,
data entry, data integrity, and registry
maintenance
Use the registry to generate reminders and
care planning tools for individual patients
© 2004 Institute for Healthcare Improvement
Integrating It
(20 minutes)
In your small groups, identify key Clinical
Information System resources, and how you
would use them to support decision support,
delivery system design, and selfmanagement support. (15 minutes)
Be prepared to tell the large group one
highlight of these discussions. (2 minutes)
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
© 2004 Institute for Healthcare Improvement
Web Resources
 http://www.bayerinstitute.com provides provider
training in “choices and changes”
 http://www.improvingchroniccare.org provides
information on the Chronic Care Model
 http://www.iom.edu/includes/DBFile.asp?id=41
24 leads to the IOM Report: “Crossing the
Quality Chasm”
© 2004 Institute for Healthcare Improvement
Web Resources
 http://www.motivationalinterview.org has books,
videos and training
 http://www.stanford.edu/group/perc home of
chronic disease and positive self-management
programs
 http://hab.hrsa.gov/ HIV and AIDS Bureau
website
© 2004 Institute for Healthcare Improvement
References
 Bodenheimer T, Lorig K, Holman H, Grumbach
K. Patient self-management of chronic disease
in primary care. JAMA. 2002 Nov
20;288(19):2469-2475.
 Gifford AL, Groessl EJ. Chronic disease selfmanagement and adherence to HIV
medications. J Acquir Immune Defic Syndr.
2002 Dec 15;31(Suppl 3):S163-S166.
© 2004 Institute for Healthcare Improvement