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The Chronic Care Model : A Framework for Improving Care for Your Patients. Lisa M. Letourneau MD, MPH MaineHealth 2006. Objectives . Describe model for improving chronic illness care and prevention that is… Patient-centered Interdisciplinary Evidence-based

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the chronic care model a framework for improving care for your patients

The Chronic Care Model:A Framework for Improving Care for Your Patients

Lisa M. Letourneau MD, MPH



  • Describe model for improving chronic illness care and prevention that is…
    • Patient-centered
    • Interdisciplinary
    • Evidence-based
  • Demonstrate how Chronic Care Model can provide an effective framework for practices to improve care
why change meet ms d
Why Change? Meet Ms. D.
  • 46 yr old mother, wife, & bookkeeper
  • Seen by PCP 4X/ in past 6mos - multiple c/o’s
  • Sx: fatigue, non-specific sx
  • PE: Wgt 180, BP 145/92, no other abnl findings
  • Initial dx stress, ?depression
the story of ms d
The Story of Ms. D…
  • On 3rd visit, fasting blood sugar 145:”borderline” diabetes
  • Advised to “watch diet, lose weight”
  • 1 yr later: Wgt 182, BP 150/90; Fasting blood sugar 165
  • PCP prescribes: metformin
  • Doesn’t pick up meds (too expensive)
  • 6 mos later: seen by coverage for blurred vision, headaches
  • Unable to work for past X2 wks
  • Blood sugar 450
ms d atypical or too familiar
Ms. D: Atypical, or too-familiar?

“Usual” chronic illness care…

  • Oriented to acute illness
  • Focus on symptoms, tests, lab results
  • Focus on physician’s treatment, not patient’s role in management
  • Interaction frustrating for both patient and doctor
  • Incentives favor “expeditious resolution”, not targeted outcomes
time for a different approach
Time for a Different Approach?
  • Emphasis for change to date has been on physician, not system
  • Characteristics of successful, evidence-based interventions weren’t being categorized usefully
  • Common interventions that improve outcomes across chronic conditions not fully appreciated
essential elements of good care
Essential Elements of Good Care









Improved Outcomes


(Chronic) Care Model

Health System


Health Care Organization

Resources and Policies




Self-Management Support





Practice Team






Improved Outcomes

self management support
Self-Management Support
  • Support patient’s ability to manage their own condition
  • Identify what’s important to your patient
  • Use effective behavior change methods
  • Make the patient a partner in care – can require a culture shift!
supporting self management
Supporting Self-Management

What are the barriers?

  • Lack of standard messages, education materials
  • Limited time
  • Many providers not well trained in science of behavior change
  • Lack of, unfamiliarity with self-care tools
  • Other…
self management support1
Self-management Support
  • Use standard, basic patient education materials to give repeated, consistent messages
  • Use self-care tools (e.g. self-care card, goal-setting sheets), assess confidence, identify barriers for making change
  • Encourage referrals for formal self-management education and training (e.g. diabetes self-management training, asthma education, cardiac rehab)
moving beyond compliance
Think differently!

Focus on collaborative goal setting with patients

Effectively support behavior change with patients:

Do you want to make a change?

How are you going to make the change?

What can I do to help you?

Moving beyond “compliance”…

“Non-compliant patient”

changing your role
Changing Your Role…

“Education is not the filling of a pail, but the lighting of a fire”

William Butler Yeats

collaborative goal setting tools
How important is the change to the patient?

How confident are they that they can make the change?

Collaborative Goal-Setting Tools

1 2 3 4 5 6 7 8 9 10

  • What barriers are likely to get in the way?
delivery system design
Create a supportive practice team

Doc can’t do it alone – need everyone to work up to their full capacity

Everyone has a role – identify and train staff to maximize their role

Delivery System Design
barriers to using a team approach
Barriers to Using a Team Approach?
  • Culture shift! (for some…)
  • Roles for team members not clearly defined
  • Training needs?
  • Communication channels
what characterizes a prepared practice team
What Characterizes a “Prepared” Practice Team?
  • At the time of the visit, the care team has…
  • patient information
  • decision support
  • people, equipment, and time
  • … required to deliver evidence-based clinical management and self-management support
redesigning the care team
Redesigning the Care Team
  • Use “planned care” visits (can’t rely on just acute care visits)
    • - Prepare patient for visit (bring meds, take off shoes)
    • - Use visit templates, flow sheets, standing orders
  • Provide follow-up care according to guideline recommendations
  • Consider alternative care models – e.g. group visits, follow-up phone calls
clinical decision support
Can’t rely on memory alone! (think of flying…)

Get tools into practice to help providers make the right decision – every time!

Translate guidelines into practice!

Clinical Decision Support
barriers to evidence based clinical decision making
Barriers to Evidence-based Clinical Decision Making?
  • Lack of objective assessments (e.g. BMI, depression score)
  • Fear of naming the problem (e.g. diabetes, asthma)
  • Often difficult to translate guidelines to care algorithms
  • Clinical inertia – reluctance to treat to evidence-based goals
clinical decision support1
Clinical Decision Support
  • Embed guidelines into practice by using practical tools, algorithms – e.g.

- Diabetes flow sheet; BP/glycemic control algorithms

  • Encourage case-based learning, alternative models for provider education
  • Integrate specialist expertise when needed
clinical information systems
Use data to track care & outcomes – any system can work!

Can’t measure what you can’t improve

Use your data to improve the health of individuals and populations – don’t need to wait for EMR!

Clinical Information Systems
barriers to using information systems
Barriers to Using Information Systems??
  • What information systems?
  • Unfamiliar approach
  • Time, time, time!
clinical information systems1
Clinical Information Systems
  • Any system will do
    • EMR – IF have way to look at outcomes
    • Electronic registry
    • Paper systems
  • Use clinical information systems (registry) to…
    • Summarize key issues at point of care
    • Create provider, practice reports to periodically monitor performance, provide data feedback
    • Identify high-risk pt subgroups needing proactive care
      • e.g. HbA1c>9%; pt’s without visit in past 12 mos; needing labs
the five stages of data
The “Five Stages of Data”
  • Denial

(“Those aren’t MY numbers”)

  • Anger / resentment

(“Who got those numbers?”)

  • Bargaining

(“How about if we re-run it again??…”)

  • Depression (?!!)

( “Why are we even doing this?…”)

  • Acceptance

( “How can we get better?”)

(“Stages of Grief”–E. Kubler-Ross – adapted by M. Albaum MD)

community resources
Recognize practice as situated within larger community – do you know your community?

Form partnerships with local community resources

Strengthen connections with local Healthy Maine Partnerships

Raise public awareness through community education

Community Resources
barriers to connecting with communities
Barriers to Connecting with Communities?
  • What community resources?
  • Connections not made
  • Unfamiliar roles
  • Communication channels not established
  • Time, time, time…
ms d revisited
Ms. D. Revisited
  • Hears local “pre-diabetes” PSA
  • Takes ADA “Risk Test”; books PCP visit; FBS ordered pre-visit
  • PCP dx’s Type 2 diabetes, offers “TARGET Diabetes Info” booklet, sched’s follow up visit in 2 wks
  • Follow up visit: HbA1c 8.8%; results recorded w/ pt; referred for diabetes education
  • Pt attends ADEF, self-management goals set; starts local walking program
  • Nurse calls Ms. D. 2 wks later – answers questions about med side effects, encourages f/u visit
ms d a better ending
Ms. D. – A Better Ending…
  • PCP f/u visit at 1 mo: Starts oral meds (covered by hlth plan)
  • Ms. B able to continue working; husband, kids notice significant improvements
  • HA’s, fatigue diminishing
  • Follow up PCP visit at 8 wks: sx much improved, HbA1c 8.1%
  • Plan to continue meds, taper care manager calls, f/u in 2 mos

How do Practices Make the Care Model “Real”?

  • Support patients to understand, manage their own condition(s)
  • Build on evidence-based guidelines
  • Use the tools!
    • Lots of locally-developed patient & provider tools!
  • Get support for change: MH Learning Community!
    • Educational sessions - Learn from peers
    • Tools - Coaching
  • Use “rapid cycle” framework for change (PDSA!)
getting started
Getting Started
  • What about this is exciting?
  • What about this is terrifying?
  • What do you need to be successful?
  • Let’s spend the rest of the day sharing practical ideas that will make this all possible.
it s time to start
It’s Time to Start…
  • Start where you are.
  • Use what you have.
  • Do what you can.

~ Arthur Ashe ~


For more info:

  • Chronic Care Model references

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