August 15, 2005 August 15, 2005 Presented by: Presented by: Lisa Gorski MS, APRN, BC, CRNI Lisa Gorski MS, APRN, BC, CRNI OASIS Answers, Inc. OASIS Answers, Inc. Presented for: Presented for: Colorado Foundation Colorado Foundation for Medical Care for Medical Care APPLYING PRINICIPLES OF THE CHRONIC CARE MODEL TO IMPROVE HOME HEALTH OUTCOMES copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 2 Objectives .. Describe the components of the Chronic Care Model. .. Identify ways to incorporate concepts of the Chronic Care Model into home health care practice. .. Utilize strategies & tools that emphasize collaborative interactions with patients. copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 3 Why Focus On Chronic Conditions? .. Chronic conditions - those that last longer than 3 months & are not selflimiting .. Account for 75% of health care cost in the US .. Affect 99 million Americans - 41 million have limited ADL's - 12 million unable to live independently copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 4 Deficiencies In Care For The Chronically Ill .. Rushed practitioners not following established practice guidelines .. Not addressing adherence to long term therapies to manage chronic illness .. Health care worker skills - lack of skills in assessing adherence/risk and developing interventions; lack of patient tailored interventions .. Lack of care coordination .. Lack of active follow-up .. Patients not adequately trained/educated to manage their illness copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 5 History of the Chronic Care Model .. First published in 1998 by Dr. Edward Wagner .. Work of the Group Health Cooperative of Puget Sound, Seattle, Washington .. Web site: www.improvingchroniccare.org copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 6 Criticisms of Other Models: Case Management & Disease Management .. Focus primarily on reduction in cost .. Focus on highest cost patients .. Focus taken away from primary care physician and delegated to case manager .. Evidence based care vs. focus on utilization review?? The Chronic Care Model copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 8 Overview of the Chronic Care Model Functional and Clinical Outcomes Productive Interactions Informed, Activated Patient Prepared, Proactive Practice Team 1. Community Resources and Policies Delivery System Design 4. Decision Support 5. 6. Clinical Information Systems Self- Management Support 3. 2. Health System Organization of Health Care Chronic Care Model image used with ICIC permission. ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 9 .. Community Resources & Policies .. Mobilize community resources to meet patient needs .. Encourage patients to participate in community programs that are effective - Exercise programs - Senior centers - Self help groups .. Form partnerships with community organizations to support & develop interventions to fill gaps in needed services .. Advocate for policies to improve patient care copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 10 .. Health System Organization of Health Care .. Create a culture, organization, and mechanisms that promote high quality care .. Visibly support improvement at all levels of the organization .. Promote effective improvement strategies aimed at comprehensive system change .. Encourage open and systematic handling of errors and quality problems to improve care .. Provide incentives based on quality of care .. Develop agreements that facilitate care coordination within and across organizations copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 11 .. Self-Management Support .. Patients become their own primary "caregiver" when they have a chronic illness - Considerable portions of self management are under direct control by the patient .. Self-management support empowers and prepares patients to manage their health and health care .. The patient's central role in managing their health is emphasized .. Effective self-management support strategies include assessment, collaborative goal setting, action planning, problem solving and follow-up .. Internal and community resources should be organized to provide ongoing self-management support to patients copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 12 .. Delivery System Design .. Assure delivery of effective, efficient clinical care & self-management support .. Define roles and distribute tasks among team members .. Use planned interactions to support evidence based care .. Provide clinical case management services for complex patients .. Ensure regular follow-up by the care team .. Give care that patients understand and that fits with their cultural background copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 13 .. Decision Support .. Promote clinical care consistent with scientific evidence & patient preferences .. Embed evidence based guidelines into daily clinical practice .. Share evidence based guidelines and information with patients to encourage their participation .. Integrate specialist expertise and primary care copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 14 .. Clinical Information Systems .. Organize patient and population date to facilitate efficient and effective care .. Provide timely reminders for providers & patients .. Identify relevant subpopulations for proactive care .. Facilitate individual patient care planning .. Share information with patients and providers to coordinate care .. Monitor performance of practice team and care system copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 15 Obstacles to Adopting the Chronic Care Model .. Reimbursement .. Need for visionary leaders .. Cost of clinical information systems .. Lack of time of clinicians .. But.. portions of the model can be implemented... copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 16 How Can Home Care Integrate this Model into Practice? Questions to ask ourselves: .. Do we provide care within our own "silo" or do we ensure linkage with other organizations & community resources to optimize outcomes? .. How do we work together more effectively with physicians, other health care providers, and community resources? .. Do we ensure that our practice is based on evidence, current research, accepted standards of practice? .. Do we incorporate successful self-management support strategies into our care? copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 17 Evidence Based Practice Guidelines .. Are staff educated in evidence based practice (EBP)? Do they know what it means? .. Are agency policies, procedures, protocols, pathways, etc. based on, and referenced to, existing EBP guidelines that are applicable & appropriate to home care practice? .. Does documentation system support consistent processes for care based on EBP? copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 18 Integration of EBP Guidelines into Home Care Practice: Examples .. Home Infusion Therapy - 2002 Guidelines by the Centers for Disease Control (CDC) .. Falls Prevention: Research based interventions most likely to be beneficial - Muscle strengthening and balance training individually prescribed by trained health care professionals - Tai-chi group exercise - For those with a falls history --Home hazard assessment and modification - Withdrawal of psychotropic medications copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 19 Integration of EBP Guidelines into Home Care Practice: Examples .. Diabetes .. Hypertension .. Heart Failure .. COPD .. Urinary catheter management copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 20 Self Management Support .. Home care clinicians can/should implement - involves collaboration with the patient .. Self management support . patient education .. Traditional--and often typical-- home care patient education - Clinician's "agenda" - Assumes that . knowledge will create patient behavioral change - Goal of "compliance" copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 21 Self Management Support .. Collaborative interactions - Patient's agenda - Assumes that . confidence in ability to change plus knowledge will create patient behavioral change - Goal of increased confidence in ability to change copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 22 Examples of interventions that align with Chronic Care Model .. Patient is: - Asked for ideas to integrate into treatment plan - Given choices - Asked about problems - Shown that what s/he did influenced condition - Helped with setting specific goals - Asked how chronic condition affects life - Encouraged to attend community programs Reference: Patient Assessment of Chronic Illness Care (2004) www.improvingchroniccare.org/tools/pacic.htm copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 23 Self Management Support .. Specific Strategies include: - Collaborative decision making - Information giving: ask, tell, ask - Information giving: closing the loop - Collaborative decision making: assessing readiness to change - Collaborative decision making: goal setting .. Reasonable, patient "do-able," behavior specific .. What, how much, when, how often California Healthcare Foundation, 2005, www.chcf.org copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 24 Problem Solving With Patients .. Change takes time & effort & perseverance! .. Identify problems in patient plan .. Generate ideas to solve it - choose one option .. Try it (establish time frame) .. Evaluate results .. If the first idea doesn't work, try another idea .. Consider additional resources .. Foster hope and confidence that eventually it will work! copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 25 Some Examples of Tools that Support Self Management .. ICIC Tools - SELF-MANAGEMENT SUPPORT PATIENT PLANNING WORKSHEET - Stoplight Tools .. DIABETES .. HEART FAILURE .. ASTHMA http://www.improvingchroniccare.org/tools/criticaltools.html copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 26 Some Examples of Tools that Support Self Management .. OASIS Answers Best Practice Tools - MANAGING YOUR MEDICINES - PATIENT ACTION PLAN FOR HF SIGNS/SYMPTOMS - CHECK FOR SAFETY: A HOME FALL PREVENTION CHECKLIST FOR OLDER ADULTS .. Other Examples - MY BLOOD PRESSURE WALLET CARD - CONTROL YOUR DIABETES FOR LIFE: TIPS TO HELP YOU FEEL BETTER AND STAY HEALTHY copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 27 Conclusion .. Chronic illnesses are prevalent among our home care patients .. It is often challenging to help these patients remain at an optimal level of wellness and stay out of the hospital .. The Chronic Care Model provides a guide that predicts improvement when the 6 interrelated components of the model are addressed and improved copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 28 Selected References .. Bodenheimer, T, MacGregor, K & Sharifi, C (2005) Helping patients manage their chronic conditions. Available online: www.chcf.org .. Bodenheimer, T, Wagner, EH & Grumbach, K (2002) Improving primary care for patients with chronic illness. JAMA 288, 1775- 1779. .. Bodenheimer, T, Wagner, EH & Grumbach, K (2002) Improving primary care for patients with chronic illness: The Chronic Care Model, Part 2. JAMA 288, 1909-1914. .. World Health Organization (2003) Adherence to long-term therapies: Evidence for action. Available online: .. Web site for the Chronic Care Model. www.improvingchroniccare.org copyright 2005 OASIS Answers, Inc. www.oasisanswers.com 29 Thank you... Colorado Foundation for Medical Care Join us next week: August 22, 2005 12:00-1:15 Mountain "How OASIS Accuracy Impacts Quality"