Planned Chronic Care Visits Tom Bodenheimer UCSF Department of Family and Community Medicine.

Planned Chronic Care Planned Chronic Care VisitsVisits

Tom BodenheimerTom Bodenheimer

UCSF Department of Family and UCSF Department of Family and Community MedicineCommunity Medicine

Tyranny of the Tyranny of the urgenturgent

Tyranny of the urgentTyranny of the urgent

• Primary care clinicians have too many Primary care clinicians have too many issues to deal with in the average 18 issues to deal with in the average 18 minute visitminute visit

• Acute problems crowd out time for Acute problems crowd out time for routine management of chronic illnessroutine management of chronic illness

Chronic Care Model componentsChronic Care Model components • Decision supportDecision support

– Clinical practice guidelinesClinical practice guidelines– Clinician educationClinician education

• Delivery system redesignDelivery system redesign

Planned visitsPlanned visits – Case managementCase management– Primary care teamsPrimary care teams

• Clinical information systemsClinical information systems– Clinician feedbackClinician feedback– RemindersReminders– RegistriesRegistries

• Self-management supportSelf-management support

What is a Planned Visit?What is a Planned Visit?• A Planned Visit is an encounter with the patient A Planned Visit is an encounter with the patient

initiated by the practice to focus on aspects of care initiated by the practice to focus on aspects of care that typically are not delivered during an acute that typically are not delivered during an acute care visit.care visit.

• The provider’s objective is to deliver evidence-The provider’s objective is to deliver evidence-based clinical management and patient self-based clinical management and patient self-management support at regularly scheduled management support at regularly scheduled intervals without the “noise” inherent in the acute intervals without the “noise” inherent in the acute care visit.care visit.

Delivery system redesign:Delivery system redesign:Planned visitsPlanned visits

• Planned visits can combat the “tyranny of the Planned visits can combat the “tyranny of the urgent” by separating chronic care and acute urgent” by separating chronic care and acute visitsvisits

• Planned visits for people with relatively stable Planned visits for people with relatively stable chronic illness -- or chronic illness that requires chronic illness -- or chronic illness that requires a lot of patient education, collaborative decision a lot of patient education, collaborative decision making, and goal setting -- could be performed making, and goal setting -- could be performed by nurses, pharmacists, or other caregivers by nurses, pharmacists, or other caregivers using physician-created protocolsusing physician-created protocols


• Planned group visits for diabetics significantly Planned group visits for diabetics significantly reduced HbA1c levels and hospital use for reduced HbA1c levels and hospital use for diabetics in Kaiser system (RCT) diabetics in Kaiser system (RCT) [Sadur et al. Diabetes [Sadur et al. Diabetes Care 1999;22:2011] Care 1999;22:2011]

• Individual planned diabetes mini-clinic visits Individual planned diabetes mini-clinic visits can improve outcomes if the patients actually can improve outcomes if the patients actually come to the visits come to the visits [[Wagner EH et al. Diabetes Care Wagner EH et al. Diabetes Care 2001;25:695.]2001;25:695.]

.

Delivery system redesign Delivery system redesign and and clinical information systems:clinical information systems:

planned visits + remindersplanned visits + reminders

A Cochrane Review looked at trials A Cochrane Review looked at trials comparing a control group with patients comparing a control group with patients who had planned follow-up visits who had planned follow-up visits andand whose physicians had reminder prompts. whose physicians had reminder prompts. 5 trials were found: the intervention 5 trials were found: the intervention group had significantly lower HbA1c in group had significantly lower HbA1c in all 5 trials. all 5 trials. [Griffin, Kinmouth. Cochrane Review, 2001][Griffin, Kinmouth. Cochrane Review, 2001]


• A Danish study of 970 patients with A Danish study of 970 patients with diabetes cared for by 474 physicians, diabetes cared for by 474 physicians, comparing usual care with planned visits comparing usual care with planned visits and other improvements, found that and other improvements, found that HbA1c, blood pressure, and lipids were HbA1c, blood pressure, and lipids were significantly lower in the intervention significantly lower in the intervention group. group. Olivarius et al. BMJ 2001;323:970.Olivarius et al. BMJ 2001;323:970.


• Peters and Davidson demonstrated that Peters and Davidson demonstrated that patients attending a nurse-led diabetes patients attending a nurse-led diabetes planned visit clinic had improved HbA1c planned visit clinic had improved HbA1c levels that were also lower than usual levels that were also lower than usual care patients. Aubert came to similar care patients. Aubert came to similar conclusions. conclusions. Peters and Davidson, Diabetes Care 1998;21:1037Peters and Davidson, Diabetes Care 1998;21:1037

Aubert et al. Annals Intern Med 1998;129:605.Aubert et al. Annals Intern Med 1998;129:605.


• According to a Cochrane review, seven studies in According to a Cochrane review, seven studies in which nurses conducted planned diabetes care which nurses conducted planned diabetes care visits all demonstrated a positive impact on visits all demonstrated a positive impact on glycemic control. The review concluded that glycemic control. The review concluded that nurses “can even replace physicians in delivering nurses “can even replace physicians in delivering many aspects of diabetes care, if detailed many aspects of diabetes care, if detailed management protocols are available, or if they management protocols are available, or if they receive training.” receive training.”

Renders et al. Interventions to improve the management of diabetes Renders et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. mellitus in primary care, outpatient and community settings. Cochrane Review. In Cochrane Library Issue 3, 2001. Cochrane Review. In Cochrane Library Issue 3, 2001.

Self-management supportSelf-management support

• Educating patients about their specific Educating patients about their specific chronic disease and teaching them chronic disease and teaching them technical skillstechnical skills

• Training patients in problem-solving and Training patients in problem-solving and goal-setting skills to assist in healthy goal-setting skills to assist in healthy behavior changebehavior change

Self-management supportSelf-management supportBoth aspects of self-management support are needed. Both aspects of self-management support are needed.

Example: diabetesExample: diabetes

• Comprehensive review of traditional patient education: 33/46 Comprehensive review of traditional patient education: 33/46 studies showed improved patient knowledge/ skills, but only studies showed improved patient knowledge/ skills, but only 18/54 demonstrated improved glycemic control 18/54 demonstrated improved glycemic control [Norris et al. [Norris et al. Diabetes Care 2001;24:561]Diabetes Care 2001;24:561]

• Adding problem-solving/goal setting skills training reduces Adding problem-solving/goal setting skills training reduces

HbA1c compared with controlsHbA1c compared with controls [Anderson et al. Diabetes Care [Anderson et al. Diabetes Care 1995;18:943]1995;18:943]


• Planned visits can do both aspects of Planned visits can do both aspects of self-management support -- patient self-management support -- patient education and collaborative goal-education and collaborative goal-settingsetting

• The best planned visits also do The best planned visits also do medication management medication management


• Can be individual visits or group Can be individual visits or group visitsvisits

What does a Planned Visit look What does a Planned Visit look like?like?

• The provider team proactively calls in patients for a The provider team proactively calls in patients for a longer visit (20-40 minutes) to systematically review longer visit (20-40 minutes) to systematically review care priorities. care priorities.

• Visits occur at regular intervals as determined by Visits occur at regular intervals as determined by provider and patient. provider and patient.

• Team members have clear roles and tasks. Team members have clear roles and tasks. • Delivery of clinical management and patient self-Delivery of clinical management and patient self-

management support are the key aspects of care.management support are the key aspects of care.• Protocols need to be prepared before initiating planned Protocols need to be prepared before initiating planned

visits that include medication managementvisits that include medication management

Example: Patients with type 2 Example: Patients with type 2 diabetes. Step Onediabetes. Step One

• Choose a patient sub-population, e.g., all Choose a patient sub-population, e.g., all patients A1c >9.5 from registrypatients A1c >9.5 from registry

• Identify patients who have not been seen Identify patients who have not been seen recently as prioritiesrecently as priorities

• Review chart for needed medical Review chart for needed medical managementmanagement

Step Two: Patient OutreachStep Two: Patient Outreach

• Have front office call patient and explain the need Have front office call patient and explain the need for planned visitfor planned visit

• Allow patient to choose day and time for visitAllow patient to choose day and time for visit• Ask patient to come to lab for A1c one week prior to Ask patient to come to lab for A1c one week prior to

visitvisit• Ask patient to bring in all medications and any Ask patient to bring in all medications and any

blood sugar datablood sugar data

• MA prints patient summary from MA prints patient summary from registries and attaches to front of chartregistries and attaches to front of chart

• Care manager (usually nurse or Care manager (usually nurse or pharmacist) who runs the planned visit pharmacist) who runs the planned visit reviews medications and labs prior to reviews medications and labs prior to visit, and consults with physician as visit, and consults with physician as neededneeded

Step Three: Preparing for the Step Three: Preparing for the VisitVisit

• Review and tweak patient’s medication regimenReview and tweak patient’s medication regimen• Examine feetExamine feet• Referrals for eye care/other specialties as neededReferrals for eye care/other specialties as needed• Self-management educationSelf-management education• Self-management goal setting with an patient Self-management goal setting with an patient

action planaction plan• Schedule follow-upSchedule follow-up• Different team members can do different Different team members can do different

portions of these tasksportions of these tasks

Step Four: The VisitStep Four: The Visit

• Does not need to be in-person visit (use Does not need to be in-person visit (use phone, email)phone, email)

• Check success in achieving action planCheck success in achieving action plan

• Problem solve as neededProblem solve as needed

• Schedule additional follow-up as neededSchedule additional follow-up as needed

Step Five: Follow-upStep Five: Follow-up

My personal viewMy personal view

• To initiate chronic care improvement in To initiate chronic care improvement in public hospital systems, changing public hospital systems, changing primary care is the hardest, because the primary care is the hardest, because the daily stresses are so greatdaily stresses are so great

• A good way to start is the Lyn Berry/ A good way to start is the Lyn Berry/ Phyllis Preciado strategy at Alameda Phyllis Preciado strategy at Alameda County Medical Center: start with a County Medical Center: start with a planned care clinicplanned care clinic

My personal viewMy personal view• A planned care clinic can often be A planned care clinic can often be

established with no budget or a very established with no budget or a very small budget. It requires senior leader small budget. It requires senior leader support to arrange space and assign the support to arrange space and assign the necessary personnel to the planned care necessary personnel to the planned care clinic 1 day or 1/2 day per week. clinic 1 day or 1/2 day per week.

• Appointment clerk, medical assistant, Appointment clerk, medical assistant, health educator, pharmacist, nurse, health educator, pharmacist, nurse, physician. Also, use studentsphysician. Also, use students

My personal viewMy personal view

• In a planned care clinic one can start to initiate chronic care In a planned care clinic one can start to initiate chronic care model components on a small scale, later to be spread to primary model components on a small scale, later to be spread to primary care sitescare sites

– Registry with reminder systemRegistry with reminder system

– Self management education including collaborative goal Self management education including collaborative goal settingsetting

– Team development with clear division of laborTeam development with clear division of labor

– Creating simple practice guidelines embedded in a Creating simple practice guidelines embedded in a diabetes/CV risk reduction progress notediabetes/CV risk reduction progress note

– The clinic is training nurses and pharmacists to do case The clinic is training nurses and pharmacists to do case management for diabetes/CV risk reductionmanagement for diabetes/CV risk reduction

Five basic types of group visitsFive basic types of group visits

Three Clinical:Three Clinical:• Cooperative Care ClinicCooperative Care Clinic• Continuing Care ClinicsContinuing Care Clinics• Nurse-led group visitsNurse-led group visits

Two Social SupportTwo Social Support::• Chronic Disease Self-management ProgramChronic Disease Self-management Program• Support GroupsSupport Groups

DIGMAs: Drop In Group Medical DIGMAs: Drop In Group Medical Appointments?Appointments?

•Anecdotal data onlyAnecdotal data only

•Undergoing trial at presentUndergoing trial at present

•Provider satisfaction is highProvider satisfaction is high

• Increased productivityIncreased productivity

Described extensively by NoffsingerDescribed extensively by Noffsinger

Some things to know about Some things to know about Group VisitsGroup Visits

• Can be logistically tough to organizeCan be logistically tough to organize• Once established, excellent economies of scaleOnce established, excellent economies of scale• High patient satisfactionHigh patient satisfaction• 30-40% of patients will enroll30-40% of patients will enroll• Excellent way to utilize other clinical/non-Excellent way to utilize other clinical/non-

clinical staffclinical staff• HIPPA concerns easily addressedHIPPA concerns easily addressed

Bottom line:Bottom line:

Planned visits, whether group Planned visits, whether group or individual, are key to or individual, are key to improved chronic careimproved chronic care

Planned Chronic Care Visits Tom Bodenheimer UCSF Department of Family and Community Medicine.

Documents

diabetes care

planned visits reminders

planned group visits

acute care visit

visits wagner

aspects of care

protocolsplanned visits

acute visitsplanned