Organization of Diabetes Care Alireza Esteghamati,MD Professor of Endocrinology and Metabolism Tehran University of Medical Sciences
The Chronic Care Model Improving Care for People Living with diabetes
Objectives • Define the problem in today’s health care systems • State 5 useful aims to keep in mind while seeking to improve care • Describe the development of the Chronic Care Model (CCM) • List the 6 components of the CCM
Key Points • Diabetes is a chronic disease that requires proactive, planned and population-based care • It takes a team. Diabetes care should involve a interdisciplinary team working within the chronic care model • Technology (telehealth, reminder systems, EMRs, etc.) can be used to improve care
A New Health system for the 21st Century • “The current care systems can not do the job.” • “Trying harder will not work.” • “Changing care systems will.”
Six Aims for Improving Health Systems • Safe: avoids injuries (no needless deaths, accidents, or injuries) • Effective: relies on latestscientific knowledge • Patient-centered: responsive to patient needs, values, and preferences • Timely: avoids delays • Efficient: avoids waste • Equitable: quality unrelated topersonal characteristics (everyone, everywhere can receive )
Implications for How to Change Practice • If the problem is the system, and not the individual “bad apples,” then the focus for practice improvement needs to shift. • Need to make the right thing to do the easy thing to do. 7
Usual Chronic Illness Care • 15 minute visit, poorly organized • Symptoms and lab results focus of discussion and exam, not preventive assessment • Patient’s attempts to discuss difficulties in living with the condition are discouraged
Usual Chronic Illness Care • Focus is on physician’s treatment, not patient’s role in management. • Treatment plan is limited to prescription refill and encouragement to make appointment if not feeling well • Visit ends with physician rifling through drawers looking for a pamphlet
Rationale for Population Based CareThe current care delivery system was design for acute episodic care and does a poor job for chronic and preventive care. Until there is fundamental system change we will not do much better than the following: • Evidence based caregiven only 55% of time • (NEJM. 2003;348(26):2635-2645) • Blood sugaris controlled in only 37% of patients with diabetes • (JAMA. 2004:291(3):335-342) • Blood Pressureis controlled in only 35% of patients with hypertension • (Ann Intern Med. 2006;145(3):165-175) “Every system is perfectly designed to get the results it gets”
Usual Care Model Health System • Health Care Organization • Leadership concerned about the bottom line • Incentives favor more frequent, shorter visits • No organized QI Community • Resources and Policies • No links with community agencies or resources Clinical Information Systems Don’t know pts or what they need Self-Management Support No systematic approach; didactic in orientation Decision Support No agreement on good care; traditional referrals Delivery System Design Reliance on short, unplanned visits Frustrating Problem-Centered Interactions Uninformed, Passive Patient Unprepared Practice Team Sub-optimal Functional and Clinical Outcomes
Reality: Guidelines are NOT Followed Care gap between diabetes management guidelines and real-life practice Organizational and evidence-based approach to treating chronic diseases Real Life Ideal Practice
Chronic Care for a Chronic Disease Acute and reactive Proactive, planned, and population-based The Chronic Care Model
To Change Outcomes Requires Fundamental Practice Change Reviews of interventions in several conditions show that effective practice changes are similar across conditions. Integrated changes with components directed at: • Influencing physician behavior • Better use of non-physician team members • Enhancements to information systems • Plannedencounters • Modern self-management support • Care management for high risk patients
Chronic Care Model Informed, Activated Patient Supportive, Integrated Community Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes Satisfaction Clinical Measures Cost External Review Measures
Themes in the Chronic Care Model • Evidence-based • Valuing excellence (and evidence) over autonomy • Patient-centered • Each patient is the only patient • Population-based
The Chronic Care Model Community Health System Resources and Policies Health Care Organization DeliverySystem Design Decision Support Family Education & Self- Management Support ClinicalInformationSystems Informed, Activated Patient Prepared, Proactive Practice Team Supportive, Integrated Community Productive Interactions Functional and Clinical Outcomes
Elements of the Chronic Care Model 1. Delivery Systems Design: The Team 2. Self-Management Support 3. Decision Support 4. Clinical Information Systems 5. Community 6. Health Systems
Chronic Care Model Community Resources and Policies Health System Health System Health Care Organization ClinicalInformationSystems Family Education & Self-Management Support DeliverySystem Design Decision Support • Specific goals in organizations strategic/business plan • Senior leader support • Organization adopts performance improvement model • Provider incentives support organizational goals
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 incentivesbased on quality of care. • Develop agreements for care coordination.
Chronic Care Model Health System Community Health Care Organization Resources and Policies DeliverySystem Design ClinicalInformationSystems Decision Support Family Education & Self- Management Support • Evidence-based guidelines • Provider education • Referrals and specialist expertise • Guidelines for patients
Decision Support • Embed evidence-based guidelines into daily clinical practice. • Integrate specialist expertise and primary care. • Use proven providereducation methods. • Share guidelines and information with patients.
Chronic Care Model Community Resources and Policies Health System Health Care Organization Family Education & Self-Management Support DeliverySystem Design Decision Support ClinicalInformationSystems • Emphasize patient/parent active role • Collaborative care planning/problem solving • Ongoing educational process • Connections between family/patient and social support • Standardized assessments of self-management • Written management plan with goal setting
Self-Management Support • Formerly known as Diabetes Education • Shift from didactic diabetes education to a patient-empowering motivationalapproach Problem-solving and goal-setting
Self-Management Support • Emphasize the patient's central role. • Use effective self-management support strategies that include: assessment goal-setting action planning problem-solving follow-up. • Organize resources to provide support.
Chronic Care Model Health System Community Resources and Policies Health Care Organization ClinicalInformationSystems Decision Support Family Education & Self-Management Support DeliverySystem Design • Team roles and tasks (practice team, school, parents) • Care based on accepted guidelines • Primary care team assures continuity • Regular follow-up care
Delivery System Design • Define roles and distribute tasks among team members. • Use planned interactions to support evidence-based care. • Provide clinical case management services for high risk patients. • Ensure regular follow-up. • Give care that patients understand and that fits their culture.
Delivery Systems Design: The Team • Expertise of nurses, dietitians, pharmacists, and psychological support • Team working with primary care physicians supported by specialists • Disease management model that uses patient education, coaching, treatment adjustment, monitoring, care co-ordination
Your diabetes care team may include a ……. You Local diabetes education centre Optometrist or ophthalmologist Kidney specialist Physical activity specialist YOU Dentist Heart specialist Family and friends Mental Health Professional Foot care specialist Other people you know who have diabetes
Chronic Care Model Community Resources and Policies Health System Health Care Organization ClinicalInformationSystems Family Education & Self-Management Support DeliverySystem Design Decision Support • Registry to track clinically useful and timely information • Registry reports/data for feedback • Care reminders • Assure timely planned follow-up • Identification/proactive care of relevant patient subgroups • Individual patient care planning
Chronic Care Model Community Resources and Policies Health System Health Care Organization ClinicalInformationSystems Family Education & Self-Management Support DeliverySystem Design Decision Support • Partnerships • Key school contact identified • Input • Educational services available
Community Resources and Policies • Encourage patients to participate in effective programs. • Form partnerships with community organizations to support or develop programs. • Advocate for policies to improve care.
Essential Element of Good Chronic Illness Care Prepared Practice Team Informed, Activated Patient Productive Interactions
Informed, Activated Patient What characterizes an “informed, activated patient”? They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it.
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 patient’s self-management • The provider is viewed as a guide on the side, not the sage on the stage!
What characterizes a “prepared” practice team? Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care.
Prepared Practice Team Has the: • Patient information • Decision support • People • Equipment • Time To deliver: • Evidence-based clinical management • Self-management support
How would I recognize a productive interaction? Prepared Practice Team Informed, Activated Patient Productive Interactions • Assessment of self-management skills and confidence as well as clinical status. • Tailoring of clinical management by stepped protocol. • Collaborative goal-setting and problem-solving resulting in a shared care plan. • Active, sustained follow-up.
Self-Management Education (SME) A systematic intervention that involves active patient participation in self-monitoring and/or decision-making
Key Points • Diabetes self-management education (SME) improves health parameters • SME should teach behaviours as well as knowledge and technical/problem-solving skills • SME should be patient-centred, tailored to the individual, use a variety of teaching methods and be regularly reinforced
Knowledge is Power • Empowering patients through self-management education improves: • A1C • Quality of life • Weight loss • Cardiovascular fitness
Basic Knowledge and Skills • Monitoring health parameters (including SMBG]) • Healthy eating • Physical activity • Pharmacotherapy and medication adjustment • Hypo-/hyperglycemia prevention/management • Prevention and surveillance of complications • Problem identification and solving
Not Just Knowledge: Work on Behavior! • Cognitive-behavioral interventions improve self-management and metabolic outcomes • They may involve: • Cognitive re-structuring • Problem-solving • Cognitive-behavioural therapy (CBT) • Stress management • Goal setting • Relaxation
How should SME be delivered? Personal contact with healthcare workers Combination of group and individual sessions Combination of didactic and interactive Interdisciplinary team and/or peer-education
Self-Management Support This section contains: • 5A’s Self-Management support forms • Goal Setting form • Patient education handouts
Using the 5 “A’s” With Diabetes • Assess • Advise • Agree • Assist • Arrange
Using the 5 “A’s” With Diabetes Assess: What does the patient know about diabetes. Are they ready to learn? What are their values and culture? • Advise: Prioritize an individual plan for your patient in partnership with them. • Agree: Start with goals patient has identified and assist them in creating ways to meet their goals.
Using the 5 “A’s” With Diabetes • Assist: Develop a long-term plan for the patients which is agreed upon by both patient and provider. Assist patient in identifying barriers to success. • Arrange: Continue to follow-up and assist patient