Understanding & Improving the Quality of Chronic Care:

Moving Beyond the Vanguard PracticesBrian AustinDeputy Director Improving Chronic Illness CareAcademyHealth Annual Research MeetingJune 7, 2004

ICIC Mission and Initial StrategyMissionTo assist health systems, especially those serving low income populations, improve their care of the chronically ill through quality improvement, research, and disseminationStrategyQI - use Breakthrough Series to promote CCM-guided system change, and externally evaluateResearch - promote innovation in care delivery through research grants and our own researchDissemination - spread advances and tools in chronic care (and help build field) through direct communication with potential users, and through partnerships

Funded through a grant from The Robert Wood Johnson Foundation

A Recipe for Improving OutcomesLearningModel

System Change StrategyLearning ModelA Recipe for Improving Outcomes

What are we trying to

accomplish?

How will we know that a

change is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

The CollaborativeLearning Model

Select Topic

Planning Group

Identify Change Concepts

Participants

Prework

LS 1

P

S

A

D

P

S

A

D

LS 3

LS 2

Action Period SupportsE-mailVisits Web-sitePhoneAssessments Senior Leader Reports

Event

A

D

P

S

(12 months time frame)

Saw this diagram in LS #1. It might make more sense now.Think about how you learned and what helped and what didn't.What will help your colleagues in spread?Probably punctuated learning.Communication methods.Just enough information.

Variations on the Chronic Care Model

WHOs Care for Chronic Conditions Framework

Evolution of Regional Collaborative StrategyWA experience demonstrated advantages of regional approachBuilds capacity for broader, sustained activityOpportunity to engage plans, payors, and governmentSocial relationships add powerICIC funded collaborative sponsors like QIOs or State health departments (seven grantees)Several have conducted multiple collaborativesCollaboratives Plusadding system change capacity to regional QI

Regional CollaborativesWashington State: Diabetes I,II, IIIAlaskaOregon: Diabetes, CHFChicagoVermontNew MexicoWisconsinNorth CarolinaRhode IslandMaineArizonaNevadaColorado

A Steady Rise in ParticipantsNote: Represents approx. 150,000 pts in pilot populations

Chart6

32

163

453

623

798

1110

Cumulative # of Teams

Chart1

Chart2

Sheet1

Enter new data below then go to pivot table area, give a right mouse click, and hit "Refresh Data"

NameTeamsTypePatients*Start Date

17 teams WSDC I17Regional17001999

22 teams WSDC II22Regional22002000Cumulative # of Teams

10 teams AK10Regional10002000199832

17 teams ODC17Regional170020011999163

11 teams NM11Regional110020012000453

8 teams arthritis8Regional80020022001623

11 teams VTDC11Regional110020012002798

17 teams Chicago DC17Regional1700200220031110

10 teams GHC IC I10Regional10002000

17 teams GHC IC II17Regional17002001

32 teams -- Chronic I32IHI32001998

26 teams -- Chronic II26IHI26001999

50 teams -- Chronic III50IHI50002000

80 teams -- HIV80IHI80002000

Wash State III Diabetes & Prev.28Regional28002003

Nevada10Regional10002003

Arizona10Regional10002003

Maine12Regional12002003

Rhode Island10Regional10002003

Indiana21Regional21002003

New York City17Regional17002003

North Carolina14Regional14002003

ODC CHF7Regional7002003

88 teams -- Diabetes I88BPHC165121999

118 teams -- Diabetes II118BPHC218882000

93 teams --- Diabetes IV and CVD I93BPHC128792001

21 teams -- Asthma II21BPHC21002001

Collabapalooza134BPHC200482002

Collabapalooza II142BPHC235192003

Cancer Prevention Pilot7BPHC7002002

Prevention7BPHC7002003

IMPACT network (adapted care model)43IHI63002002

BPHC Subtotal454

Total to Date1110

For a conservative estimate, assume 100 per team except for BPHC, where we used their reported numbers

The BPHC Diabetes I and II were given as a single figure.

150346Pivot Table of Collaboratives per Year

Start DateNameTeams

BPHC:610199832

IHI& ICIC National:23132 teams -- Chronic I32

Regional:269

11101999131

17 teams WSDC I17

26 teams -- Chronic II26

88 teams -- Diabetes I88

2000290

10 teams AK10

10 teams GHC IC I10

118 teams -- Diabetes II118

234622 teams WSDC II22

50 teams -- Chronic III50

80 teams -- HIV80

2001170

11 teams NM11

11 teams VTDC11

17 teams GHC IC II17

17 teams ODC17

21 teams -- Asthma II21

93 teams --- Diabetes IV and CVD I93

2002159

17 teams Chicago DC17

8 teams arthritis8

Collabapalooza134

2003129

Wash State III Diabetes & Prev.28

Nevada10

Arizona10

Maine12

Rhode Island10

North Carolina14

Indiana21

New York City17

ODC CHF7

Grand Total911

Sheet1

32

163

453

623

798

1110

Cumulative # of Teams

Cumulative Count of Collaborative Teams

Sheet2

Sheet3

ICIC Involvement in Chronic Care Improvement

Types of Systems Participating in Regional CollaborativesNote: This does not include BPHC collaboratives.

Pie Chart of systems types

99

29

38

28

47

Sheet1

CollaborativeSafety NetAcademicIntegratedManaged CareOtherTotal

Alaska300069

ODC14644018

NM2121410

WSDC13170617

WSDC2140411130

WSC80821028

NYCHHC17000017

IN16500021

AZ12416023

RI3440011

Chicago3440011

OR CHF000527

NC8320013

VT2100811

ME4029015

9929382847241

non-duplicated counts. Please note, many safety net providers are also clinical sites for academic institutions, as are some integrated and managed care systems. Other is primarily small, privately owned clinics.

Safety NetAcademicIntegratedManaged CareOther

9929382847

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Indiana: An Example of Collaboratives Plus

Indiana: Program Objectives

Provide consistently high quality care to Medicaid recipients that improves health status, enhances quality of life and teaches self management skills. Reduce the overall cost of providing health care to Medicaid patients suffering from chronic diseases.Provide support to primary care providers and integrate primary care with case management.Utilize and strengthen the public health infrastructure.Achieve long term results by changing the way primary care is delivered across the state, not just for Medicaid.

Assembling the Infrastructure Assemble best pieces to build and strengthen the existing public that will facilitate the interaction health infrastructure between primary care and chronic disease case management statewideState Health Department clinical expertise, physician committees, medical community tiesExisting Vendors member enrollment, reminder calls to patients, inbound and outbound call center, data integration Community Partners community health centers, FQHCs, public health associations, minority health coalitions and other community entities to offer face to face case management Technology - data registry that facilitates efficient communication between call center, case managers and physicians and also provides adequate reporting functionality

Main Program ComponentsProgram Management: Medicaid and Health are jointly responsible for the program including policy development, contracting and monitoring performance. Primary Care: The focal point of patient care is the primary care physician. Key elements of the Indiana CDM program are designed to provide information & resources to support the physician. Care Management. Care management is comprised of:A Call Center that monitors patient status and follow-up based on the established protocols. A Nurse Care Manager network whose nurses provide more intense follow up and support to high risk patients. Patient Data Registry. An electronic data registry is available to physicians and can be used for all patients. For Medicaid patients, it will be populated with claims data and case management data.Measurement & Evaluation. Measures of program performance are being established using both claims history data and individual health outcomes indicators for both an intervention & control group.

Case Management Client FlowCommunity ResourcesSelf Management Training Nurse Case Management 15 - 20% of PatientsPatient Registry CDMS Web-BasedChronic Care Model Collaborative Training Decision SupportCall Center 80 - 85% of PatientsPatientProvider

Indiana Program Implementation Schedule

PeriodRegionCondition StateJuly December 2003CentralCHF, Diabetes

January March 2004NorthernCHF, Diabetes, Asthma (also add asthma for Central)April June 2004SouthernCHF, Diabetes, AsthmaJuly September 2004StatewideHigh risk patients

Bringing System Change to Small Practices Practice redesign is very difficult in the absence of a larger, supportive systemSystemness (and measurable improvement) in the US generally comes from a larger organization (e.g., BPHC, Kaiser, VA)In addition to limited staff and IT, smaller practices need additional help because of multiple health plans, reduced reimbursement and productivity pressuresIs it possible to develop a regional strategy that can bring support and systemness to large numbers of practices?

Systemness as a Community PropertyCommunity entity provides: Leadership and integration via coalitionPerformance measurement Financial incentivesModels of changePrograms for learning and disseminationShared infrastructureGuidelinesIT software and supportCare managementConsumer education

Improved Community OutcomesWidespread Practice ChangeHealth Systems in a Community

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

Delivery SystemDesign

DecisionSupport

Clinical Information Systems

Self- Management Support

Health System

Resources and Policies

Community

Health Care Organization

www.improvingchroniccare.orgContact us: Thanks

Advantages of a General System Change ModelCommonalities 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 easierEmphasis on system, not physician behaviorApplicable to most preventive and chronic care issues

Informed,ActivatedPatientProductiveInteractionsPrepared,ProactivePractice TeamDelivery SystemDesignDecisionSupport Clinical Information SystemsSelf- Management SupportHealth SystemResources and PoliciesCommunity Health Care OrganizationChronic Care ModelImproved Outcomes

Essential Element of Good Chronic Illness CareInformed,ActivatedPatientProductiveInteractions

PreparedPractice Team

What characterizes a prepared practice team?PreparedPractice TeamAt the time of the visit, they have the patient information, decision support, people, equipment, and time required to deliver evidence-based clinical management and self-management support

What characterizes a informed, activated patient?Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patients self-management. The provider is viewed as a guide on the side, not the sage on the stage! Informed,ActivatedPatient

Assessment of self-management skills and confidence as well as clinical statusTailoring of clinical management by stepped protocolCollaborative goal-setting and problem-solving resulting in a shared care planActive, sustained follow-upInformed,ActivatedPatientProductiveInteractions

PreparedPractice TeamHow would I recognize aproductive interaction?

Self-management SupportEmphasize 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

Delivery System DesignDefine 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

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

Clinical Information SystemProvide 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.

Health Care OrganizationVisibly 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.

Community Resources and PoliciesEncourage patients to participate in effective programs.Form partnerships with community organizations to support or develop programs.Advocate for policies to improve care.

What are we trying toaccomplish?How will we know that achange is an improvement?What change can we make thatwill result in improvement?Model for Improvement

Chronic Conditions Breakthrough Series

Select TopicPlanning GroupIdentify Change ConceptsParticipantsPreworkLS 1PSADPSADLS 3LS 2SupportsE-mailVisits Web-sitePhoneAssessments Senior Leader ReportsNatl.C.ADPS(13 months time frame)

We now know it takes knowledge from a wide range of fields to improve care. Well be talking about three different kinds of knowledge and put them in a learning model so that we can take it all in.The first is about clinical carewhat the best clinical care is for each condition.The second is about system designwhat do we know about how to design a system so that good care is the outcome.The third is a strategy to change our current system while we are still working so that it becomes the best systemAnd we put this all in a strategy to learn thema learning model, the collaborative.Now we have to address how to change partwhich brings us to the Model for Improvement and the Breakthrough Series Collaborative, developed by IHI and APIThe policy environment is now the biggest ellipse. The patient-provider interaction has a new partner, the community supporters, forming a triad.More detail