What will it Take to Improve Care for Chronic Illness for the Population? Ed Wagner, MD, MPH MacColl Institute for Healthcare Innovation Center for Health.

What will it Take to Improve Care for Chronic Illness for the Population?

Ed Wagner, MD, MPH

MacColl Institute for Healthcare InnovationCenter for Health StudiesGroup Health Cooperative

Improving Chronic Illness CareA national program of the Robert Wood Johnson Foundation

Step 1: Find the causes of inadequate care.

IOM Quality Chasm Report:

“The current care systems cannot do the job.”

“Trying harder will not work.”

“Changing care systems will.”

What Patients with Chronic Illnesses Need

• A “continuous healing relationship” with a care team and practice system organized to meet their needs for:

Effective Treatment (clinical, behavioral, supportive),

Information and support for their self-management,

Systematic follow-up and assessment tailored to clinical severity,

More intensive management during high risk periods, and

Coordination of care across settings and professionals

What’s Responsible for the Quality Chasm?

• A system oriented to acute disease that isn’t working for patients with long-term care needs or the professionals caring for them

Step 2: Select a strategy

Three Options:

1. Assume that competition and computers willimprove care

2. Direct to patient disease management

3. Improve medical care by changing care systems

Why is it critical that we change care systems?

• The human and financial costs of chronic disease are heavily determined by the level and duration of disease control

• Without high quality medical care, disease control measures like HbA1c, BP, LDL tend to plateau or slowly worsen over time

• It is difficult (maybe impossible) to deal with the many attitudinal, behavioral and pharmacologic issues associated with poor control in currently designed care systems.

Why?

1. Some patients simply fall between the cracks and many practices have neither the data nor mechanisms to find them.

2. If care consists largely of patient-initiated visits for new problems, there usually isn’t time to optimize:

• Patient understanding and involvement

• Medication adherence

• Self-management competence

• The drug regimen

3. Many patients with less than optimal control need more intensive management and follow-up than practices usually provide

What kind of changes to practice systems improve care?

better use of non-physician team members,

planned encounters, modern self-management

support Care management for high risk Links to effective community

resources guidelines integrated into care enhancements to information

systems (registries)

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Outcomes

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Current status of Chronic Care Model

• National measurement and pay for performance programs – NCQA

• State initiatives – California, Vermont, Pennsylvania, North Carolina, etc.

• New models of Primary Care AAFP – combines CCM, medical home, and pay for coordination and performance

ACP – “advanced medical home” has same three ingredients

The Evidence Base

Does the CCM Work?

Organizing the Evidence

1. Randomized controlled trials (RCTs) of interventions to improve chronic care

2. Studies of the relationship between organizational characteristics and quality improvement

3. Evaluations of the use of the CCM in Quality Improvement

4. RCTs of CCM-based interventions

5. Cost-effectiveness studies

1: Randomized Controlled Trials of Interventions to Improve Chronic Care

• Most reviews are disease specific.

• Reviews and meta-analyses tend to focus on individual components rather than combined effects.

• Diabetes reviews played an important role in CCM development.

1: Randomized trials of system change interventions: Diabetes

Cochrane Collaborative Review and JAMA Re-review

• About 40 studies, mostly randomized trials

• Interventions classified as decision support, delivery system design, information systems, or self-management support

• 19 of 20 studies that included a self-management component improved care.

• All five studies with interventions in all four domains had positive impacts on patients.

Renders et al, Diabetes Care, 2001; 24:1821

Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910

• “Complex,” “integrated care,” programs show positive effects on quality of care

• Consistently powerful elements include: team care, case management, self-management support

1: RCTs of interventions to improve chronic care results

1: An Example of a Meta-analysis of interventions to improve chronic illness

• Includes 112 studies, most RCTs (27 asthma, 21 CHF, 33 depression, 31 diabetes)

• Interventions that contained one or more CCM elements improved clinical outcomes (RR .75-.82) and processes of care (RR 1.30-1.61)

• No superfluous element

• Didn’t study interactive effectsTsai AC, Morton SC, Mangione CM, Keeler EB. Am J Manag Care. 2005 Aug;11(8):478-88.

2: Studies of the Relationship between Organizational Characteristics and Quality

Studies by CMS, NCQA and others have shown strong correlations between practice consistency with the CCM and diabetes performance indicators.

3: Evaluations of the Use of CCM in Quality Improvement

• Largest concentration of literature

• Includes RAND Evaluation of ICIC

• Wide variety in quality and type of evaluation designs

• Majority of studies focus on diabetes

3: RAND Evaluation of Chronic Care Collaboratives

• Two major evaluation questions:1. Can busy practices implement the CCM?2. If so, would their patients benefit?

• Studied 51 organizations in four different collaboratives, 2132 BTS patients, 1837 controls with asthma , CHF, diabetes

• Controls generally from other practices in organization

• Data included patient and staff surveys, medical record reviews

3: RAND FindingsImplementation of the CCM

• Organizations made average of 48 changes in 5.8/6 CCM areas

• One year later, over 75% of sites had sustained changes, and a similar number had spread to new sites or new conditions.

3: RAND Findings (2)Patient Impacts

• Diabetes pilot patients had significantly reduced CVD risk (pilot > control), resulting in a reduced risk of one cardiovascular disease event for every 48 patients exposed.

• CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days and fewer ER visits

• Asthma and diabetes pilot patients more likely to receive appropriate therapy

• Asthma pilot patients had better QOL

3: Non-RAND Evaluations of CCM Implementation

• In general, those studies with greater fidelity to the CCM showed greater improvements.

• All but one showed improvement on some process measures.

• Most showed improvement on outcomes and empowerment measures, as well.

• Recent evaluation shows cost-effectiveness of collaborative participation-- $33,000/QALY

4: Randomized Controlled Trials (RCT) of CCM-based Interventions

• 6 RCTs covering asthma, diabetes, bipolar disorder, comorbid depression and oncology, and multiple conditions

• 5 in the US – disease specific, 1 in Australia – multiple diseases

• Practice-level randomization

• All showed positive effects on process, and all but one on outcomes

Step 3—Reach the Majority of Practices

Lessons learned in chronic illness care improvement

• Chronic care collaboratives have demonstrated that practices can make these changes and improve care

• Mostly reaching early adopters

• Practice redesign is very difficult in the absence of a larger, supportive “system”, especially for smaller practices

• How to help isolated small practices where 80% of Americans receive their care?

• How do the VA, Kaiser achieve high quality?

But, the VA and Kaiser are organizations with leaders, money, fairly clear business goals, and staff who share those goals. Is there anything analogous in the community?

*King’s Fund Study

Organizational factors supportive of high quality chronic care*:

• Strategic values and leadership that support long term investment in managing chronic diseases

• Investment in information technology systems and other infrastructure to support chronic care

• Use of performance measures and financial incentives to shape clinical behavior

• Active programs of Quality Improvement based on explicit models

What’s needed to improve chronic illness care for the population?

• Commitment and Leadership

• Measurement (and incentives)

• Infrastructure support

• Active program of practice change

Step 4—Build a regional healthcare “system”

But, who might do it, and what would they do?

A Framework for Regional Quality Improvement

• Data sources were a literature review, interviewswith leaders of major coalitions directed at quality, and lessons learned in helping launch the PSHA

• The goal is to provide a visual summary of what leading coalitions were doing—I.e. not an evidence-based model

A Framework for

Regional Quality

Improvement

Leadership

•www.improvingchroniccare.org

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