# Presentation: 045147

## Slide 1

**Notes:**
Title slide

## Brief overview of chronic disease 

**Brief overview of chronic disease**** **
**The evidence**
**The *****Chronic Care Model***
**The  IHS Chronic Disease Workgroup**
**Summary of the Workgroup’s meetings**
**Development of the *****draft***** strategic plan**
**Proposed IHS Chronic Disease Strategic Plan**

**Notes:**
Outline of my talk

## Chronic Disease in the U.S. 

**Chronic disease has replaced acute disease as the dominant health problem**
** ****Chronic disease is now the principal cause of disability & use of health services**
** ****Chronic disease consumes 78% of health expenditures**

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
Facts about chronic disease in the U.S.

## Chronic Disease in the U.S. The Role of the Patient

**Chronic disease dramatically transformed the role of the patient**
** ****Chronic disease requires behavior change to forestall worsening of disease**
** ****Patient lives with multiple consequences, including social & economic dislocation, emotional turmoil, financial fear, lowered self-esteem & depression**

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
The role of the patient in chronic disease has dramatically changed

## Chronic Disease in the U.S. 

** ****the role of the patient:**
** ****As a result of chronic illness, the patient becomes experienced **
** ****Often more knowledgeable than physician about the *****effects***** of the disease & its treatment**
** ****Thus develops an integral role in treatment process**

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
Facts about chronic disease in the U.S.

## Differences between acute and chronic disease

-  Acute = episodic
-  commonly a cure
-  inexperienced, passive patient
-  physician administers treatment

-  chronic = continuous
-  rarely a cure
-  patient lives indefinitely with the disease, symptoms & consequences
-  persistent treatment
-  patient has integral role in the treatment process

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
Differences between acute and chronic disease (consider the management implications for our health care system here)

## The IOM Quality report: A New Health System for the 21st Century

**http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument**

**Notes:**
In 2001, the Institute of Medicine published this report.  What we have in the US is not a gap between what we know is good care and what we do, it is a chasm.

## The IOM Quality Report:Selected Quotes

**The IOM Quality Report:*****Selected Quotes***

**“****The current care systems *****cannot****** *****do the job.”**
**“****Trying harder will *****not***** work.”**
**“****Changing care systems *****will*****.”**

**Notes:**
Here are some quotes from the report.

These are very applicable to Chronic Care

## Systems are perfectly designed to get the results they achieve

**Systems are perfectly**** designed to get the**** results they achieve**

**The Watchword**

**Notes:**
Source, Don Berwick

## The practice of chronic care medicine requires a different approach

** ****The nature of care changes over time**
** ****Must be managed over time as disease evolves with shifting severity, pace & treatments**
** ****Good management is an unfolding process, best provided by a multi-disciplinary team of professionals**
** ****Continuity & integration of care are essential**

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
We have to change our approach to accommodate good quality chronic disease care

## The practice of chronic care medicine requires a different approach

-  Sites of care change
-  Role of the physician changes
-  Role of the patient changes

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
Changes require a different approach in all aspects of the health care system: sites of care as well as the roles that people play

## The evidence for a new approach to chronic care medicine

-  **evidence strongly suggests that**:
-  a knowledgeable patient achieves better outcomes
-  a collaborative physician improves *both *understanding by patient & health outcomes
-  different modes of clinical practice yield favorable health outcomes with less expense, esp. for patients with chronic disease
-  IOM reports underscore that quality care depends on changes in current medical practice & education

- Holman H. JAMA Vol 292, No.9, Sept 1, 2004

**Notes:**
The evidence for taking a different approach to chronic illness care.

## Chronic Care Model

**Informed,**
**Activated**
**Patient**

**Productive**
**Interactions**

**Prepared,**
**Proactive**
**Practice Team**

**Improved Outcomes**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Chronic Care Model**

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

**Notes:**
Premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community.  Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient.  It is the most visible part of care to the patient, followed by the delivery system design.  They know what kind of appointments they get, and who they see.  They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care.  We’ll talk about each in detail in the following slides.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66. 
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14. 
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78. 

## Components of the Chronic Care Model

-  **1. Health care organization**
** ****2. Community resources**
** ****3. Decision support**
** ****4. Clinical information systems**
** ****5. Delivery system redesign**
** ****6. Self-management support**

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

**Notes:**
The 6 key components of the chronic care model

## Components of the Chronic Care Model

** ****1. **_**Health care organization**_
-  Visibly support improvement at all levels, starting with senior leaders
- Promote effective improvement strategies aimed at comprehensive system change.
- Encourage open and systematic handling of problems.
- Provide incentives based on quality of care.
- Develop agreements for care coordination.

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

**Notes:**
Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care. 
1)Visible support for leaders is believed to be critical for ongoing success. Ovretveit et al. Quality collaboratives:lessons from research. Qual Saf Health Care 2002;11:345-351. Senior leaders provide support by visiting clinical sites, reviewing monthly reports, providing resources and problem-solving for innovators. This support of change in pursuit of better quality care becomes part of the culture of the organization and everyone has a role in quality.
2) Some QI strategies work.  Langley and colleagues have categorized what they learned from helping  organizations institute improvements.  References on Effective QI: Walshe & Freeman Qual Saf Health Care 2002 Mar;11(1):85-87. Langley et al: The Improvement Guide, Jossey Bass, 1996
3) Encourage open and systematic handling of errors and quality problems to improve care . Safety  has been a rallying cry for inpatient care and is becoming a concern in outpatient care.  The system needs to be open and  honest about handling errors in care and shortcomings in quality. IOM Quality chasm
4) Examples of provider incentive: Medical Assistance Administration (Medicaid) in Washington state pays for group clinical visits for asthma and diabetes when lead by an MD or ARNP. Includes assessment, treatment planning, group discussion on prevention of exacerbations or complications, proper use of medications and monitoring and living with chronic illness, Q&A, BP, wt, one on one to gather data and review individual treatment plan.  Pays ~$20, 4 times/yr.) Reward care teams for quality of care, not just productivity.  Not always monetary but through recognition, attending CME. Not just physician providers.  
Bonuses for MDs for quality care: employers and health plans starting bonus programs, $50-100 per patient for BP control, lower lipids, blood sugar.  Some programs reward establishing a registry, providing pt education and having regular follow-up (Boston Globe 11/7/2002, p A1)  Endsley et al FPM March 2004.
5) Develop agreements that facilitate care coordination within and across organizations.  Work with local hospitals, VNS, social service agencies in an open and coordinated manner. IOM Quality Chasm

## Components of the Chronic Care Model

-  **2. **_**Community resources**_
- Encourage patients to participate in effective programs.
- Form partnerships with community organizations to support or develop programs.
- Advocate for policies to improve care.

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

## Components of the Chronic Care Model

-  **3. **_**Decision support**_
-  Embed evidence-based guidelines into daily clinical practice.
- Integrate specialist expertise and primary care.
- Use proven provider education methods.
- Share guidelines and information with patients.

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

## Components of the Chronic Care Model

-   **4. **_**Clinical information systems**_
- Provide reminders for providers and patients.
- Identify relevant patient subpopulations for proactive care.
- Facilitate individual patient care planning.
- Share information with providers and patients.
- Monitor performance of team and system.

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

**Notes:**
Clinical information system:  Organize patient and population data to facilitate efficient and effective care.
Many of you may think of this as a registry, but these information systems range from card files to fully functional electronic health records and everything in between. Whatever our system, we need it to perform be able to do these things for us.
1) Provide timely care reminders for providers and patients (Our CIS will prompt reminders to perform needed labs or exams.)
2) Identify relevant patient subpopulations can be identified for proactive care. (Such as to notify all the smokers of a new cessation program, invite patients to a group meeting, or alter medications if some new therapy is shown to be beneficial.)
3) Individual patient care planning is facilitated by the information system. (Care plan is stored and can be adjusted as patient changes their routine and care is adjusted.)
4) Information can be shared with patients and providers.  Print outs, care summaries, and communications from distant sites are all ways to increase the efficiency and quality of care we can provide.
5) Monitor performance of practice team and care system—the RPMS provides us feedback on how we are doing by provider, clinic or entire system. This feedback loop is valuable information for us to learn from what we are testing and the changes we are trying in our settings.

## Components of the Chronic Care Model

-  **5. **_**Delivery system re-design**_
- Define roles and distribute tasks amongst team members.
- Use planned interactions to support evidence-based care.
- Provide clinical case management services.
- Ensure regular follow-up.
- Give care that patients understand and that fits their culture

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

**Notes:**
Delivery system design:  Assure the delivery of effective, efficient clinical care and self-management support.
Delivery system design is where we all work everyday--(WHO is there and WHAT do they do to contribute to good quality care. This is about HOW we interact with patients.)
1) Sometimes people who work together don’t really work together. We are talking about actually having a team who discusses the work they do and how they are going to do it and how to improve on it. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998;11(2):116-26. 
2) Planned interactions have an agenda, like a routine physical has a known agenda. These can be either 1:1 or in groups. We can use prompts and tools to help set the agenda and not leave out critical parts of the care. McCulloch et al Effective Clinical Practice 1998;1:12-22 and Disease Management 2000;3(2):75-82 
3) Many of the effective chronic disease programs use case or care managers, but many of us in clinic settings don’t have a way to make care managers a part of our team. What we can do is to determine what it is the care managers are doing that improved care, and make those tasks part of our system. We also need to reserve these intensive services for patients who really need them, the complex patients, either because of multiple conditions, complicated treatment routines or for psychosocial reasons. Simon et al. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550
4) Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In real estate, they say, Location, Location, Location. In chronic illness, it is Follow-up, Follow-up, Follow-up.
Support for telephone follow-up: Nurses increase exercise in elderly primary care pts using phone calls: Journal of Geront: Medical Sciences 2002 vol 57A no 11 M733-M740.  
Impact of automated phone calls and nurse calls on diabetes in the VA, RCT Piette et al, Diabetes Care 2001;24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction)
5) Give care that patients understand and that fits with their cultural background.  This goes beyond providing interpretation but being aware of our values, beliefs and communication style, and adapting to meet patient needs.

## Components of the Chronic Care Model

-  **6. **_**Self-management support**_
- Emphasize the patient's central role.
- Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.
- Organize resources to provide support
** **

- Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

**Notes:**
Self-management support:  Empower and prepare patients to manage their health and health care.
1)  Emphasize the patient’s central role in managing their health. Providers emphasize the patient's active and central role in managing their illness. (Health care team is only with patients a very brief amt. of time.)
2) Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up.
5 A’s is an office-based way to help patients with behavior change.
Assessments include not only knowledge but beliefs and behavior.  (Knowledge isn’t enough to change behavior. We need to understand more about what patients value and what they do.)
Advice needs to be given carefully and linked to things that are important to patients. For example, graphing lowered blood sugars after a patient has successful exercised regularly.
Agree on goals that are important to patients.  Goals are usually broken down into smaller steps (typically called action plans) that lead to better outcomes.
Assist with problem-solving by identifying barriers, strategies and social or environmental support.
Arrange a specific follow-up plan. Follow-up is not left to chance and can be done in person, over the phone or via email, or by using peers and outreach workers.
Review: Effectiveness of SM training for diabetes Norris et al, Diabetes Care 2001;24:561
Glasgow et al in submission
3)  Organize internal and community resources to provide ongoing self-management support to patients.

## Brief overview of chronic disease 

**Brief overview of chronic disease**** **
**The evidence**
**The *****Chronic Care Model***
**The  IHS Chronic Disease Workgroup**
**Summary of the Workgroup’s meetings**
**Development of the *****draft***** strategic plan**
**Proposed IHS Chronic Disease Strategic Plan**

**Notes:**
Outline of my talk

## Summary of the first meeting of the IHS Chronic Care Working Group (12/04)

** ****Goal:****	****to develop a strategic plan for the Indian health system to approach chronic disease in a coordinated manner**
** ****Objective: address 3 questions**
**What does the Indian health system need to address chronic disease?**
**Can the Indian health system work together to address chronic disease?**
**What are the next steps to move forward?**

**Notes:**
The IHS established the Chronic Care Working Group (CCWG) that includes health professionals from the IHS, Urban Indian Health Institute at the Seattle Indian Health Board, McColl Institute of Group Health Cooperative, Veterans Administration, and Institute for Healthcare Improvement.  The goal of the CCWG is to develop a strategic plan for the Indian health system to approach chronic disease in a coordinated manner.  
On December 1, 2004, the IHS held the first CCWG meeting in Seattle, Washington.  The objective of this first meeting was to address the following questions:
What Does the Indian Health System Need to Address Chronic Disease?
The CCWG felt that a number of system changes are needed for the Indian health system to better address chronic disease.  The CCWG envisioned an Indian health system where policy supports innovation, specialist expertise is shared among all communities, traditional roles of health professionals are re-examined, and the system allows itself to take ownership and credit for the progress it makes in addressing chronic disease.  
Can the Indian Health System Work Together to Address Chronic Disease?
Overall, the CCWG felt that working together would be efficient and integrated, support innovation, provide the opportunity to redesign policies and procedures, and encourage partnerships and collaboration.  On the other hand, the CCWG felt addressing chronic care as a group would pose significant challenges such as completing an entire system redesign, implementing change across the whole system, communicating across a large and varied group, continuing to deal with acute care needs, and finding the funds necessary to address chronic care.  
What Are the Next Steps Needed to Move the Chronic Care Initiative Forward?
To produce a strategic plan to address chronic disease, the CCWG decided that the following activities needed to be completed: (1) determine the evaluation plan for the initiative; (2) adopt and re-work the Chronic Care Model and World Health Organization Framework[1] to fit the Indian health system; (3) and establish pilot sites to inform the development of the initiative.

## Recommendations from the IHS Chronic Care Working Group

-  **Working Goal**** **
**In FY2006 we will implement a system of chronic disease management (the Chronic Care Model), focused on improving outcomes in metabolic syndrome related diseases in a finite number of locations. CVD risk reduction, metabolic syndrome and depression are of interest. **

**Notes:**
The Chronic Care Workgroup developed this goal: In FY2006 we will implement a system of chronic disease management (the Chronic Care Model), focused on improving outcomes in metabolic syndrome related diseases in a finite number of locations. CVD risk reduction, metabolic syndrome and depression are of interest. 

## Summary of the first meeting of the IHS Chronic Care Working Group

**What are the next steps to move forward?**
- To produce a strategic plan to address chronic disease, the following activities needed to be completed:
- determine an *evaluation plan* for the initiative;
- adopt and *re-work* the Chronic Care Model and World Health Organization Framework to fit the Indian health system; and
- Develop a plan to establish *pilot sites* to inform the development of the initiative.
**	**

**Notes:**
Summary of our first meeting: We asked:  What Are the Next Steps Needed to Move the Chronic Care Initiative Forward?
To produce a strategic plan to address chronic disease, the CCWG decided that the following activities needed to be completed: (1) determine the evaluation plan for the initiative; (2) adopt and re-work the Chronic Care Model and World Health Organization Framework[1] to fit the Indian health system; (3) and develop a plan to establish pilot sites to inform the development of the initiative.

## Summary of the second meeting of the IHS Chronic Care Working Group

** ****3 Objectives**
- Continue to ***strengthen linkages among the multiple disciplines***** **that are addressing established, new, and emerging chronic conditions
- Create a plan to ***define a cross-cutting, integrated, and multi-disciplinary system***** **to address the prevention and treatment of chronic conditions in collaboration with key partners** **
- Begin to ***identify, develop, discuss, revise, and promote strategies***** **with timelines to accomplish the goals and objectives

**Notes:**
The second CCWG meeting took place on May 24, 2005, in Seattle, Washington.  The objectives of this meeting were to:
Continue to strengthen linkages among the multiple disciplines that are addressing established, new, and emerging chronic conditions.
Create a plan to define a cross-cutting, integrated, and multi-disciplinary system to address the prevention and treatment of chronic conditions in collaboration with key partners.
Begin to identify, develop, discuss, revise, and promote strategies with timelines to accomplish the goals and objectives.

## Recommendations from the IHS Chronic Care Working Group

**Chronic Care Subgroups**
**Training Subgroup**
**Develop an inventory of the existing training focused on chronic disease, identify gaps, and propose training plan by September 1, 2005**
**Information Systems and Metrics Development Subgroup**
**Develop an inventory of existing information management, identify evaluation metrics, and develop proposal by July 1, 2005**

**Notes:**
Four subgroups were identified at the second meeting to work on different aspects of the Strategic Plan: Training; Information Systems and Metrics Development

## Recommendations from the IHS Chronic Care Working Group

**Chronic Care Subgroups**
**Pilot Sites Subgroup**
** ****Develop criteria for pilot sites, determine which sites should serve as pilots, and develop a plan to spread the project after the pilot phase by August 1, 2005**
** ****Awareness Subgroup**
** ****Develop a marketing and awareness plan by July 1, 2005**

**Notes:**
Four subgroups were identified at the second meeting to work on different aspects of the Strategic Plan: Pilot Sites and Awareness/ MArketing

## Where is the Project?  

**Degree of belief that the changes will result in improvement**

**High**

**Prototype**

**Pilot**

**Spread**

**Successful changes**

**Changes still need further testing.  There is a risk of  moving to spread/scale-up.**

**Unsuccessful proposed changes**

**Low**

**Moderate**

**Where is the Project?**

**2005 Institute for Healthcare Improvement**

**Notes:**
At the second meeting of the Workgroup we had a presentation from the Institute for Healthcare Improvement (IHI) re the concept of “spread”. The goal of the spread framework is to enable systems to change, not to dictate or push out the change.  The spread framework is designed to help you think strategically about how you can energize your entire organization and provide the infrastructure necessary for system changes.  It illustrates how local improvements can move to system-wide change in a focused and disciplined manner.  This figure  illustrates the concept of spread. 
	As illustrated in the figure, a project can move through three stages.  The first stage is the prototype stage, when a project or idea is completely new.  In this stage, the degree of belief— based on data and facts—that system changes will result in improvement are low to moderate.  The second stage is the pilot stage.  During this stage, you can test how the project or idea works in a system.  If the pilot stage is successful, the degree of belief that system changes will result in improvement is high.  This leads to the third stage, which is spread.  It is important to keep in mind that an organization might be ready for spread in one area, but only ready for the prototype stage in another area. 

## Framework for Spread

**Phase 1: Planning and set-up**
** ****Leadership**
** ****Set-up**
**Phase 2: Communication through the Social System**
-  **Build broad awareness**
-  **Share technical information**
** ****Phase 3: Continuous Monitoring and Feedback (includes 2 feedback loops)**** **
** ****measurement and feedback**
** ****Knowledge management**

**2005 Institute for Healthcare Improvement**

**Notes:**
 Spread proceeds through several phases. Like leadership and set-up, the social system is an important element in spread. Organizations that have been successful in spreading change have implemented two elements of communication through the social system.  The first element is to build broad awareness throughout the system.  The second element is to share technical information. The spread framework also includes two feedback loops.  The first loop is measurement and feedback, which provides a system-wide evaluation of where you are heading and if you are successful.  The second loop is knowledge management, which develops the plan for spread and listens to the sites within the social system. 

## Components vital for first phase of spread

**Leadership**
** ****topic is a key strategic initiative**
** ****executive sponsor assigned**
** ****day-to-day managers - “spread agents” - identified**
** ****align goals & incentives of agency**
**Set-up**
** ****target population**
** ****are pilot sites successful?**
** ****identify key groups who make adoption decision**
** ****initial strategy to reach all sites**

**2005 Institute for Healthcare Improvement**

**Notes:**
 Leadership
At the top of the framework is leadership.  The IHI identified several leadership factors for successful spread.  First, the leadership needs to identify the project as a key strategic initiative, which is clear to everyone in the organization; this message must be sent to the organization continuously.  Second, the organization needs to designate an executive who is responsible for the project, keeps constant watch over the project, and resolves problems.  Third, the organization needs to designate a person or a team who act as the day-to-day managers, or “spread agents”, for the project.  Fourth, the goals and incentives of the organization need to be aligned.  For example, is chronic care in the organization’s business plan and its quality improvement plan?  Are the goals and incentives for providers the same throughout the system?  Are the goals and incentives the same for administrators and providers?  
Set-up
In addition to leadership, the role of set-up is critical in spreading change.  The IHI identified several set-up factors for successful spread.  First, the organization needs to be clear on their target population.  Where are the sites that have been successful?  To whom do you want to spread the practices of the successful sites?  Second, the organization needs to develop an initial plan for how it will reach the target population.  In Figure 2, the circles of the social system represent sites (e.g., Tribal health clinics) and the dotted lines represent communication strategies (i.e., how sites communicate with one another and spread ideas).  You need to know how many sites you have, where they are located in relation to one another, and where they are located in relation to successful sites.  Third, the organization needs to identify the key groups who will make the adoption decision (e.g., people who do not use the changes that you want them to make). 

## Important points for phase 1

**Very few organizations are successful in spreading change if they *****push change***
*** *****The key to long-term, successful spread is to *****pull***** people toward change, by helping them to understand that change is important to them**

**2005 Institute for Healthcare Improvement**

**Notes:**
 Key lessons learned for the first phase of spread

## Recommendations from the IHS Chronic Care Working Group

**What do we want to spread?**
**	****Evidence-based systems that will improve chronic disease outcomes at the front line (micro) level**
**Who are our target audiences?**
**	****Patients, communities, and providers**

**Notes:**
Goals for spread within the chronic disease initiative

## The Health System – in the Past?

**Notes:**
This is what most of us were taught in professional school about how the health care system is set up.  Are we still teaching this approach?  Probably – most of care in school is performed in the inpatient setting. Does this look familiar? Many health care systems continue to function this way (at least pieces of it do)

## How do we get from here to there?

- ?

**Notes:**
So if the evidence suggests that there is a better way to do this..... How do we get from where we are to where we want to be?

## Outcome Improvement

- Can’t:
- Exhort physicians to comply with practice guidelines
- Beg patients to follow treatment recommendations
- Force patients to achieve goals with which they do not agree or understand.
*Push an organization to implement changes for which they are not ready.*

**Notes:**
We know that certain things don’t work for patients, providers AND for health care organizations

## Outcome Improvement

- Can:
- Assist patients to make real treatment decisions
- Build a ***system*** that improves the care of chronic disease (as agreed upon by the patient).
- Show providers individual performance
- Show leaders of local organizations that we are ready for the next step.
*Can pull organizations to follow if improvements can be shown*

**Notes:**
If you can demonstrate that providers who use the “System” have better outcomes in their patients... they will begin to use it

## Brief overview of chronic disease 

**Brief overview of chronic disease**** **
**The evidence**
**The *****Chronic Care Model***
**The  IHS Chronic Disease Workgroup**
**Summary of the Workgroup’s meetings**
**Development of the *****draft***** strategic plan**
**Proposed IHS Chronic Disease Strategic Plan**

**Notes:**
Outline of my talk

## IHS Director’s Three Initiatives:Prevention & Treatment of Chronic Illness

-  _**Goal:**_ **The goal of this initiative is to develop and implement strategies within the Indian health system to prevent chronic illness and to provide high quality care to patients with chronic illness. **

**Notes:**
The goal of our Chronic Disease Initiative

## IHS Director’s Three Initiatives:Prevention & Treatment of Chronic Illness

_**Unanswered questions**_**:**
-  **Using a collaborative approach?**
-  effect of limited resources?
-  can IT support offset these?
-  video-conferencing? Web-based support?
-  **Implementing the CCM for multiple chronic illnesses?**
-  Addressing multiple chronic illnesses at a single facility?
-  Benefit vs divert energy from other important quality initiatives?

**Notes:**
The Chronic Care Model has been shown to be effective in improving clinical outcomes with selected chronic illnesses in a wide range of settings.  The Indian health system has experience with many of the components of the Chronic Care Model and has used them to varying degrees.  For example, a number of Indian health facilities have had successful outcomes after implementing programs similar to the Chronic Care Model, such as staged diabetes management.  

Several questions remain, however, about implementing the Chronic Care Model in the Indian health system:
Implementing the Chronic Care Model through a Collaborative approach
The Institute for Healthcare Improvement (IHI) employs the concept of a Collaborative to provide programmatic guidance and focus through coordinated training and support, communication, and sharing of lessons learned.  Facilities outside of the Indian health system that have been successful in implementing the Chronic Care Model utilized an IHI-style Collaborative approach.  
The Indian health system, however, has limited experience in implementing systems changes through an IHI-style Collaborative.  The competitive Special Diabetes Program for Indians grants are successfully using a Collaborative model, but have extensive personnel and financial resources.  We do not know if a Collaborative can be implemented with fewer resources.  Can enhanced information technology support offset the other limited resources?  Can videoconferencing and web-based training be successful in diverse Indian health program settings?
Implementing the Chronic Care Model for Multiple Chronic Illnesses
Facilities in the Indian health system that have been successful in chronic care management demonstrated a readiness for change and focused on few selected outcomes, such as glycemic control or foot care.  We do not know what effect the Chronic Care Model will have on addressing multiple chronic illnesses at a single facility, or on addressing a spectrum of different chronic illnesses at multiple facilities.  Will the coordination hold up?  Will the focus on high quality chronic care be maintained?  Will benefits extend beyond the condition addressed and effectively change the health care system, or will the effort divert energy and resources from other important quality of care initiatives?   
Pilot projects that utilize an interdisciplinary Collaborative approach to implementing the Chronic Care Model can help the Indian health system address these important questions, as well as gain experience and facilitate system-wide implementation of chronic illness care. 

## Integrating the Chronic Care Model into I/T/U System

_**Integrating the Chronic Care Model into I/T/U System**_

*Wagner. JC J Qual Improvement 2001;27:63-80*

**Notes:**
How would the Chronic Care Model look if integrated into the I/T/U system? Here is the vision of one member of the Chronic Disease Workgroup.

## Plan for Integrating Elements of the Chronic Care Model into the Indian health system

- The Chronic Care Workgroup proposes to develop a *Collaborative to support pilot projects* that will facilitate system-wide implementation of the Chronic Care Model

**Notes:**
An effective framework for improving chronic illness clinical outcomes is the Chronic Care Model.  The Indian health system has utilized many components of the Chronic Care Model, but has recognized the opportunity to build upon its experience in providing chronic illness care and move toward full integration of the Chronic Care Model.  The Chronic Care Workgroup proposes to develop a Collaborative to support pilot projects that will facilitate system-wide implementation of the Chronic Care Model. 

## Plan for Integrating Elements of the Chronic Care Model into the Indian health system

- Purpose of pilot projects is to demonstrate that system changes can improve patient outcomes across multiple chronic illnesses in a cost-effective manner.
- Will use a 3 part approach

**Notes:**
The purpose of the pilot projects is to demonstrate that changing the way we deliver care can improve patient outcomes across a variety of chronic illnesses in a cost-effective manner.  The Collaborative will also support other innovative efforts within the Indian health system to address chronic illness.  This will be accomplished through a three-part approach: 

## Plan for Integrating Elements of the Chronic Care Model into the Indian health system

**Accomplished through a 3 part approach:**
**1. Activate administrative, Tribal and clinical *****leadership***** to support the re-design of the chronic care system**
** ****2. Develop a *****Collaborative***** to implement CCM & support innovation in chronic illness care**
** ****3. Enhance our comprehensive *****clinical information management system***** (RPMS) to support chronic illness care**

**Notes:**
This will be accomplished through a three-part approach: 
Part 1:	Activate administrative, Tribal, and clinical leadership to support redesign of chronic illness care using the Chronic Care Model.
Part 2:	Develop a Collaborative to implement the Chronic Care Model and support innovation in chronic illness care throughout the Indian health system. 
Part 3:	Enhance our comprehensive clinical information management system (RPMS) to support the elements of the Chronic Care Model.

## 1. Activate administrative, Tribal and clinical leadership to support the re-design of the chronic care system

** ****Leadership at the national level**
**Executive leadership**
**Programmatic leadership**
** ****Area leadership**
** ****Tribal leadership**
**Input to the Director**
**Consultation, marketing, presentations at tribal meetings**

**Notes:**
Successful implementation of the Chronic Care Model requires organization support for quality improvement.  Leadership will direct strategic planning with the goal of obtaining input from stakeholders and fostering a culture of quality improvement.  
Leadership at the National Level
Dr. Charles Grim, IHS Director; Dr. Craig Vanderwagen, Chief Medical Officer; Sandra Haldane, Chief Nurse; and the Chairs of the Clinical Councils provide executive leadership at the national level for the chronic care initiative.  They are currently responsible for: 
Providing verbal support for the chronic care initiative at public IHS meetings.
Providing broad guidance to the chronic care initiative on issues of national concern from Congress, the Department of Health and Human Services, and other agencies and organizations.
Assisting with marketing efforts by speaking on the subject of chronic illness care and the chronic care initiative.
Encouraging Indian health leaders to lend their support to the chronic care initiative. 
Allocating essential resources of funds and personnel to support these efforts.
The IHS Division of Diabetes Treatment and Prevention, IHS Division of Epidemiology, and the Chronic Care Workgroup currently provide national programmatic oversight and leadership to the chronic care initiative.  
At the Area level, the Area Directors and their health care executive leadership team provide broad leadership support to the IHS Director’s health initiatives, including the chronic care initiative.  
Tribal Leadership 
The Tribal Leaders Diabetes Committee will review the draft strategic plan and provide input to Dr. Grim on the direction of the chronic care initiative.  In addition the committee will suggest if additional Tribal consultation on any part of the initiative is required, suggest marketing strategies, and provide presentations (or opportunities for presentations) at large Tribal meetings. 

## 1. Activate administrative, Tribal and clinical leadership to support the re-design of the chronic care system

** ****Initiative oversight and management**
**Collaborative Coordinator**
**Designated leader at each pilot site**
**Collaborative Steering Committee**
** ****Monitoring and feedback**
**National leadership assures integration with 3 initiatives**
**Pilot sites provide data and feedback**

**Notes:**
Initiative Oversight and Management 
At the national level, a Collaborative Coordinator will be hired in the IHS Division of Diabetes Treatment and Prevention or the IHS Division of Epidemiology to provide national oversight to the pilot sites.  The main responsibility of the Collaborative Coordinator will include capturing what is learned at the pilot sites and developing plans to disseminate initiative information throughout the Indian health system.  Day-to-day responsibilities will include:
Coordinating data collection among the pilot sites for aggregation, evaluation plans, RPMS programming, and implementation of the interventions.
Answering questions from pilot sites and leadership. 
Facilitating the development of training and resource materials.
Providing technical assistance and support in setting up group classes, case-management, and protocols.
Incorporating non-pilot models of innovative chronic illness care into the Collaborative.
A designated leader at each pilot site will provide day-to-day oversight.  These leaders will be responsible for:
Implementing, managing, and evaluating the initiative at the local level.
Coordinating local data collection efforts and sending the data to the national Collaborative Coordinator.
Attending Collaborative meetings along with other team members.
Participating in conference calls, videoconferences, and web-based conferences with other pilot sites.
A Collaborative Steering Committee will provide programmatic guidance and technical assistance to the Collaborative Coordinator and pilot sites.  This interdisciplinary committee will include specific expertise in chronic illness care, health information technology, and innovative systems change.
Monitoring and Feedback
National leadership will ensure that Tribal and day-to-day leaders are aware of any changes, additions, or deletions to the IHS Director’s three priority initiatives at the national, Congressional, or Department of Health and Human Services levels. 
The pilot sites will provide data and feedback to leadership on lessons learned, successes, problems encountered, and barriers (e.g., system-wide barriers and clinical barriers).  The IHS Division of Diabetes Treatment and Prevention and the IHS Division of Epidemiology will coordinate regular planning meetings for the pilot sites.

## 2. Develop a Collaborative to implement CCM & support innovation in chronic illness care

**Purpose of the Collaborative:**
** ****To support pilot projects that will facilitate system-wide implementation of the Chronic Care Model**
** ****Also to ****integrate and support non-pilot models of innovative chronic illness care in the Indian health system**

**Notes:**
Implementing the Chronic Care Model requires a Collaborative approach.  The Chronic Care Workgroup proposes to develop a Collaborative to support pilot projects that will facilitate system-wide implementation of the Chronic Care Model.  Pilot sites will be chosen to participate in the Collaborative based on their capacity to implement the Chronic Care Model.  The Collaborative will also integrate and support non-pilot models of innovative chronic illness care in the Indian health system. 

## 2. Develop a Collaborative to implement CCM & support innovation in chronic illness care

** ****Focus of the pilot projects will be on risk management of key risk factors and underlying causes of chronic illness, e.g.**
**Obesity & metabolic disorders**
**Tobacco use, environmental factors & self-management techniques**
** ****Rather than focus on individual diseases, efforts will focus on comprehensive approach to improving health**

**Notes:**
Focus of the Collaborative Pilot Projects
Chronic illnesses are the leading causes of morbidity and mortality among AI/ANs.  As mentioned in Section 1, our current health care delivery model is based on individual patient visits, which tend to focus on a single condition, complaint, or illness.  Intense attention to a single illness, however, can establish barriers to effectively addressing risk factors and underlying causes of chronic illness.  On the other hand, interventions that focus on risk management for key risk factors and underlying causes of multiple chronic illnesses can lead to a reduction in a whole host of chronic illnesses.  For example, effective management of obesity and metabolic disorders can help prevent or delay diabetes, hypertension, heart disease, and kidney disease.  Interventions that focus on tobacco use, environmental conditions, and effective self-management techniques and therapies can have a positive effect on chronic lung disease in older individuals and asthma in children.  In addition, depression, post traumatic stress disorder, and substance abuse are common, highly prevalent, and contribute to poor health in all chronic illnesses.  
The Chronic Care Model provides the Indian health system with the opportunity to: (1) take a step back from focusing efforts on individual diseases and examine the risk factors and underlying causes of chronic illness and poor health; and (2) focus efforts on a comprehensive approach to improving health in our communities.  The following are examples of conditions for which the Chronic Care Model offers opportunities for intervention:
Obesity related metabolic diseases.
Cardiovascular diseases.
Kidney diseases.
Neurologic diseases with functional impairment (e.g., stroke, dementia, cerebral palsy, children with developmental delay, and spinal cord injuries).  
Arthritis (both inflammatory and degenerative).    
Behavioral disorders, including substance abuse.  
Chronic respiratory conditions (e.g., chronic obstructive pulmonary disease (COPD) and asthma).

## 3. Enhance Clinical Information Management System (RPMS) to Support the Elements of the CCM 

**Purpose of enhancing the clinical information system:**
** ****essential component of an effective chronic care delivery system**
** ****benefits that extend well beyond chronic care and into acute care, health promotion, and disease prevention efforts**

**Notes:**
Comprehensive clinical information systems are one of the core elements of the Chronic Care Model and an essential component of an effective chronic care delivery system.  Effective chronic illness care is extremely difficult without clinical information systems that ensure ready access to key data on individual patients, as well as populations and communities of patients.  In addition, comprehensive clinical information systems have benefits that extend well beyond chronic care and into acute care, health promotion, and disease prevention efforts.

## 3. Enhance Clinical Information Management System (RPMS) to Support the Elements of the CCM 

**Components of the clinical information system have major role in other core elements of the CCM:**
** ****Community resources and policies**
** ****Health system organization  **
** ****Self-management support**
** ****Delivery system design**
** ****Decision support**

**Notes:**
The Indian health system has developed and effectively uses components of clinical information systems, such as registries, appointment and tracking systems, health summaries, prompts and reminders, links to decision support, audits, and reports.  These components also play a major role in the other five core elements of the Chronic Care Model:  
Community resources and policies
The current Indian health information system, RPMS, facilitates community and population-based disease monitoring, as well as bidirectional feedback of data to appropriate community and Tribal groups.
Health system organization  
Reports from RPMS help promote clinical quality reporting, evaluation, and tracking. 
Self-management support
RPMS can facilitate specific patient education, individual goal setting, and chronic care feedback.  This includes the patient’s ability to access pertinent medical information for their lifestyle modification.
Delivery system design
An integrated health information system assists in appropriate practice management modification and design.
Decision support
RPMS is designed to provide electronic decision support for health maintenance reminders and problem lists.

## 3. Enhance Clinical Information Management System (RPMS) to Support the Elements of the CCM 

** ****Clinical information systems at national level**
** ****Case-management systems & registries**
** ****Quality of care reports**
** ****Enhanced data capture, retrieval & support**
** ****chronic care system analyst**
** ****PCC, PCC+ and EHR templates encourage documentation**
**Summaries & reminders to reflect standards of care**

**Notes:**
Although the Indian health system has a successful track record of developing and using clinical information systems, these systems have additional potential to provide enhanced IT tools to support the chronic care initiative.  
Clinical Information Systems at the National Level
Many of the information system tools for the chronic care initiative will be enhanced and supported at the national level.  These tools will include:
Enhancement, development, and deployment of appropriate, actionable, population- and patient-based quality of care reports.  
Development and deployment of case-management systems and registries that include items that influence clinical decision making, such as behavioral risk factors.
Development of standard data capture for behavioral stages of change and goal setting within the health IT system.
Enhanced usability of data retrieval tools. 
Enhanced support, including regularly scheduled IT meetings, for Collaborative pilot sites. 
The meetings will be a combination of face-to-face meetings, web-based conferences, and videoconferences.
The IHS Office of Information Technology will establish an appropriate website for sharing information.
The meetings will include a focus on lessons learned.
Chronic care system analyst who will be hired and available to support sites using the Chronic Care Model.
Identification and evaluation of appropriate process and outcome measures. 
 Development of PCC, PCC+, and Electronic Medical Record templates that encourage documentation and enhanced data capture.
Development of health summaries and health maintenance reminders that reflect standards of care with prompts to:
Address deficits in care prescribed by guidelines (e.g., “due for lipid panel”).
Facilitate clinical decision making consistent with the guidelines (e.g., if LDL is above target and patient is not on a statin, prompt “consider starting statin”).
The IHS Office of Information Technology will also develop telemedicine and web-based support tools, as well as training modules, for the initiative.  This will also include the identification of and planning for information system integration between RPMS and enhanced home telehealth resources.

## 3. Enhance Clinical Information Management System (RPMS) to Support the Elements of the CCM 

** ****Clinical information systems at pilot site level**
** ****Rapid cycle change processes for IT system needs and improvements**
** ****Active feedback to OIT**
** ****Sharing innovations & suggestions with the Collaborative**
** ****IHS Information Technology Support Center will provide technical support for IT tools to pilot sites**

**Notes:**
The pilot sites involved in the Collaborative will be responsible for: 
Participating in rapid cycle change processes for IT system needs and improvements.
Actively participating in scheduled IT meetings.
Sharing innovations and suggestions to the Collaborative.
The IHS Information Technology Support Center will deploy and provide technical support for IT tools at the pilot sites, including:
Enhanced deployment of RPMS (defined as IHS-Electronic Medical Record ready) at pilot sites.
Production and evaluation of appropriate, actionable, population- and patient-based quality of care reports.
Deployment, integration, and evaluation of case-management systems and registries that include items that influence clinical decision making, such as risk factors.
Community involvement in data evaluation, assessment, sharing, and response to the data set.
Develop PCC, PCC+, and Electronic Medical Record templates that encourage documentation and enhanced data capture. 
Modify health summaries to reflect local standards of care.

## Draft Strategic Plan from the IHS Chronic Care Working Group

**Timeline by Fiscal Year: 2006**
** ****Implement the Chronic Care Model through an IHI-style collaborative approach**
**Roll out awareness campaign through leadership**
**Identify staff & resources**
**Establish Steering Committee**
**Ongoing monitoring & evaluation of the process**
** ****Begin with 4 pilot sites supported through the Collaborative**
**Begin pilot phase & develop business plan**
**Develop standards of care & Best Practices**
** ****Enhance IT tools in RPMS**

**Notes:**
The timeline for FY06 is an ambitious one. We will implement the CCM through a collaborative approach in 4 pilot sites and begin to enhance the IT tools within RPMS to support their activiites.

## Draft Strategic Plan from the IHS Chronic Care Working Group

**Timeline by Fiscal Year: 2007**
** ****Continue to implement the Chronic Care Model through an IHI-style collaborative approach**
**Continue awareness campaign through leadership**
**Steering Committee oversight**
**Ongoing evaluation & analysis for long-term outcomes and costs**
** ****Additional 4 (or more) pilot sites supported through the Collaborative**
** ****Enhance IT tools in RPMS**
**Bidirectional data sharing for telemedicine & RPMS packages**
**Expand IT support**

**Notes:**
In FY2007 we will continue with the collaborative approach and add an additional 4 (or more) pilot sites. In 2007 we will explore telemedicine options and expand IT support.

## Draft Strategic Plan from the IHS Chronic Care Working Group

**Timeline by Fiscal Year: 2008**
** ****Assess clinical & epidemiologic effect of implementing the CCM in I/T/Us**
** ****Revise & refine Best Practices for chronic illness care**
** ****Business plan for wide-spread implementation of CCM in Indian health system**
** ****Programmatic lessons learned: global evaluation of CCM in I/T/Us**

**Notes:**
In 2008 it will be time to assess where we are and our experience thus far, to develop and refine some Best Practices for Chronic illness care within the I/T/U system, develop a business plan for spread within our organization and evaluate our “lessons learned”

## Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives. 

**	****	****	****	****William Foster**

**Notes:**
Quote

## Strategic Plan developed by the 

**Strategic Plan developed by the **
**IHS Chronic Disease Workgroup**
**September 19, 2005**
**Chaired by Drs Kelly Acton & Nat Cobb**

**Notes:**
Final slides