# Presentation: 521171

## The Chronic Care Model: Lessons Learned and Future WorkPresentation to Chronic Care Workgroup  October 16, 2006

- Brian Austin
- MacColl Institute for Healthcare Innovation
- Center for Health Studies
- Group Health Cooperative
- Improving Chronic Illness Care
**A national program of the Robert Wood Johnson Foundation**

## What’s wrong with current systems?

**Deficits in Clinical Management**
**Deficits in Self-management Support**
**Deficits in Follow-up and Care Coordination**

## Chronic Care Model Development 1993-Present 

- Graphic guide summarizing evidence for quality improvement seemed useful
- Ideas implemented at GHC with success
- RWJF-supported conference confirmed care requirements for chronic illness
- RWJF supported planning grant
- Review and revision of CCM by advisory committee
- Interviews and site visits with 72 nominated “best practices” confirms CCM elements
- RWJF funds ICIC to study, implement, and disseminate Chronic Care Model

## Advantages of a General System Change Model

- Commonalities across chronic conditions easier to see and apply.
- Characteristics of successful interventions could be categorized usefully
- Once system changes in place, accommodating new guideline or innovation much easier
- Emphasis on system, not physician behavior
- Applicable to most preventive and chronic care issues

## Chronic Care Model

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

**Productive**
**Interactions**

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

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

**Decision**
**Support **

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

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

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Chronic Care Model**

- Improved Outcomes

**Notes:**
Our 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. 

## Can Busy Practices Change in Accord with the CCM?  Chronic Conditions Breakthrough Series (BTS)

**Year-long collaborative improvement efforts involving multiple delivery systems and faculty**
**Chronic Care Model guides system change**
**Over 1000 different health care organizations and various diseases involved to date**
**Began with national BTS but shifted to regional**
**HRSA’s Health Disparities Collaboratives-****500 community and migrant health centers**
**External evaluations of early efforts by Chin et al., RAND**

**Notes:**
We started with this, national Collaboratives

## A Recipe for Improving Outcomes

- <date/time>

**System Change Strategy**

**Learning Model**

**A Recipe for Improving Outcomes**

**Notes:**
Now we have to address “how to change” part—which brings us to the Model for Improvement and the Breakthrough Series Collaborative, developed by IHI and API

## RAND Evaluation of Chronic Care Collaboratives

- Studied 51 organizations in four different collaboratives, 2132 BTS patients, 1837 controls with diabetes, CHF, asthma
- Controls generally from other practices in organization
- Data included patient and staff surveys, medical record reviews

**http://www.rand.org/health/projects/icice/**

## RAND Findings 

**Organizations made average of 48 changes in 5.8/6 CCM areas**
**IT received most attention, community linkages the least**
**CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days**
**Asthma and diabetes pilot patients more likely to receive appropriate therapy.**
**Asthma pilot patients had better QOL**
**Diabetes pilot and control patients had significantly better glycemic control (pilot>control); ****control improvement related to spread  **

## RAND Findings: What did the Teams think?

- In phone interviews a year later, most were enthusiastic about their experience
- 82% of sites had sustained the changes
- 79% of sites had spread change to other places or diseases

## New Models of Primary Care

- AAFP – combines CCM, medical home, and pay for coordination and performance
- ACP – “advanced medical home” has same three ingredients
- Both models argue for centering care in more accessible, proactive, patient-centered primary care that seizes the responsibility for coordinating care
- In return, the new primary care will have smaller panels without income loss

**Notes:**
The American Academy of Family Physicians (AAFP) 
American College of Physicians

## Do CCM system changes impact outcomeswhen implemented outside of collaboratives?

**Fleming et al. studied 134 managed Medicare organizations**
**Collected Diabetes quality measures (HbA1c, LDL, microlabuminuria and eye exams)**
**Compared top and bottom quartiles on quality****(e.g., HbA1c>9.5– 20% vs. 50%)**
**Assessed 32 care elements based on the CCM**
**Top quartile more likely to employ CCM elements,especially: computerized reminders, ****	****practitioner involvement on QI teams, ****	****guidelines supported by academic detailing, ****	****formal self-management programs, ****	****a registry **

** **Fleming et al., AJMC 10:934, 2004

## CCM developments

**Serves as guide to state programs in Indiana, Rhode Island, Vermont, Washington, California, Indiana, Colorado and others**
**CCM foundation for NCQA and JCAHO certification for chronic disease programs**
**Several practice assessment tools now available for large and small practices**
**Academia becoming involved**

**Notes:**
Association of American Medical Colleges.
The Academic Chronic Care Collaborative is an initiative of the AAMC's Institute for Improving Clinical Care (IICC).
Twenty-two of the nation's medical schools and teaching hospitals are taking part in the AAMC's Academic Chronic Care Collaborative, including Duke, Vanderbilt, Univer of Michigan Medical School

## Lessons learned in chronic illness care improvement

**Mostly reaching early adopters**
**Regional or state-based collaboratives as effective, and offer added opportunities**
**Practice redesign is very difficult in the absence of a larger, supportive “system”, especially for smaller practices**
**But, do the successes of larger systems have relevance for the larger medical community?**
**How do we help isolated small practices where majority of Americans receive their ****care?**

## King’s Fund Study of Organizations with Best HEDIS Chronic Illness Scores

**Organizational factors supportive of high quality chronic care: **
**Strategic**** ****values and leadership that support long term investment in managing chronic**** ****diseases **
**Well aligned goals between physicians and corporate**** ****managers**
**Integration of primary and specialty care**
**Investment in information**** ****technology systems and other infrastructure to support chronic care **
**Use**** ****of performance measures and financial incentives to shape clinical behavior **
**Use of explicit improvement model—****usually the Chronic Care Model **

**BMJ  2004;328:223-225**

**Notes:**
Collaboration v competition

## BUT

- Can “systemness” be a community property?
- What are its key components?
- Lessons from successful systems and innovative community programs

**BUT**

## A Regional Framework for Improving Care

**Engaging****Consumers **
- Public disclosure
- ConsumerEducation

**Shared Data & Performance Measurement**

**  ****Aligning ****  Financing/****  Insurance**
- Benefits promotecost/effectiveness
- PerformanceIncentives

**Stakeholder Collaboration**

**Improved Quality & Reduced Costs**

**Informed,**
**Activated **
**Consumers**

**Motivated,**
**Prepared**
**Practices**

**Improving Healthcare  Delivery**
- IT Connectivity & Support
- QI Models & Activities
- Consensus Guidelines
- Care Management
- Provider Networks

**Supportive**
**Insurance &**
**Payment**

**Transformed Healthcare Delivery**** **

**- Shared Vision       - Leadership**

**A Regional Framework for Improving Care**

**Notes:**
Three sets of key stakeholders in transforming care, consumers, providers and purchasers/health insurers.
The evaluators of the Community Care Networks concluded that the more successful networks had “three-component leadership”.  
“Core leadership” including a dedicated staff leader like an Executive Director,
An “organizational driver” like a public health department that helped stabilize the coalition, give it legitimacy, and bring stakeholders together, and
 “Subsidiary leadership” provided by coalition members closest to the problem or issue being tackled.
Mays, Halverson and Kaluzny emphasize the importance of a “boundary spanner”, 

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