Chronic Care Management

Chronic Care Management Design

 Pioneered by Edward H.
Wagner, MD, MPH and
colleagues at MacColl
Institute for Healthcare
Innovation at Group Health
Cooperative of Puget
Sound, Seattle Washington*
 Supported by Robert Wood
Johnson Foundation**

*Wagner, E.H. (1998). Chronic disease management. What will it take to improve care for chronic
illness? Effective Clinical Practice, 1, 2-4.
**Improving Chronic illness Care (ICIC) is a national program supported by Robert Wood Johnson
Foundation with direction and technical assistance by Group Health Cooperative’s MacColl
Institute for Healthcare Innovation.
Chronic Care Management Premise

 Right Thing

 Right Patient

 Right Time
Chronic Care Management Model

1. Community 2. Health System

Resources and Policies Health Care Organization

3. Self-Management 4. Delivery 5. Decision 6. Clinical

Support System Support Information
Design Systems

Informed, Prepared,
Activated Productive Interactions Proactive
Patient Practice Team

Wagner, E.H. Chronic Disease Management:

What Will It Take to Improve Care for Chronic
Improved Illness? Effective Clinical Practice 1998; 1:2-4.
Outcomes Permission to reproduce model image granted
from American College of Physicians (ACP),
July 7, 2006.
Mobilize Community Resources

 Patients participate in
effective community
programs
 Form partnerships to fill
gaps in needed
services and avoid
duplicating efforts
 Advocate for policies to
improve patient care
Health System – Organization of Care

 Improvement at all levels of

the organization
 Promote effective strategies
 Open and systematic
handling of errors and
quality issues to improve
care
 Provide incentives based on
quality of care
 Facilitate care coordination
within and across
organizations
Self-Management Support

 Patient has a central

role in managing health
 Self-management
support strategies
– Assessment, goal-
setting, action planning,
problem solving, and
follow-up
 Community resources
to support self-
management
Delivery System Design

 Define roles and

distribute task
 Planned interactions for
evidence-based care
 Clinical case
management services
for complex patients
 Regular provider
initiated follow-up
 Cultural sensitive care
Decision Support

 Daily practice of
evidence-based care
 Share clinical guidelines
and information with
patients*
 Provide professional
education
 Integrate specialty and
primary care

*Agency for Healthcare Research and Quality – National Guideline Clearinghouse

[Link]
Clinical Information Systems

 Timely reminders for Registry

providers and patients tracks
individuals and populations
 Identify subpopulations
for proactive care
 Facilitate individual
patient care planning
 Share information
 Monitor outcomes

Continuous Quality Improvement

Chronic Care Management
Programs

 Comprehensive
system change

 Targeting

 Case
management
Primary Care Delivery System

Traditional
 Provide acute care
 Diagnostic and laboratory
services
 Treatment of signs and
symptoms
 Prescriptions
 Brief education
 Short appointments
 Patient-initiated follow-up
Delivery System Redesign

Traditional Reconfigured
 Provide acute care  Developed processes for CD
 Diagnostic and  Incentives for making
laboratory Services changes
 Treatment of signs and  Extensive patient education
symptoms to increase patient’s
 Prescriptions confidence and skills
 Brief education  Provider-initiated
 Short appointments appointments and follow-up
 Patient-initiated follow-  Evidence-based guidelines
up and provider interaction
 Information Systems
Targeting Approach

 Correctly assumes a small percent

of the population accounts for most
health care costs
 Possible to reduce cost based on
this method
 However, health status changes
occur frequently
 “Targeting” misses a substantial
portion of the population at risk
Case Management Approach

Many programs include:

 Brief hospitalization
Chronic Care
 Low intensity follow-up
Management
care advocates for:
 Conduct utilization
review Access to
services that are
proven to improve
outcomes
Examples: Missouri’s Chronic
Health Care Indicators, BRFSS, 2004

 69.1% of seniors (age 65+)

received a flu shot in past 12
months
 65.2% of adults with diabetes
test their blood sugar at least
once daily
 55.6% of adults with diabetes  39.9% of adults with
have participated in a course or arthritis have received a
class to manage their diabetes suggestion from their
health care provider to
 52.8% of adults (age 50+) have
exercise or engage in
ever had a lower endoscopy
physical activity to help
exam
their joint symptoms (2003)
Example: Medicaid

 A web-based system to help fee-for-

service Medicaid patients manage
chronic conditions
 Integrate APS Healthcare’s
CareConnection application with a
chronic care improvement program
 Product – “collaborative medical
record”
 Accessible to patients, providers and
health care coaches
The Advisory Board Company. (2006) Missouri creates web-based chronic care system. iHealth
Beat. Retrieved June 20, 2006 from [Link]
Incentives

 Vary across provider

organization
 May reduce patient
expenses
 May also reduce
profitable inpatient care
Providers - / +
 Poorly reimbursed
Provider groups with full-capitation + preventive services
Health Plans (deliver returns within 6-12 mo) ++
 Performance related to
Purchasers / Employers +++ defined quality goals
Governmental entities ++++

+ greater incentive to engage in disease management

Primary Care Physician Use of
Electronic Medical Records
Country Percent Using EMR
Sweden 90% EuroBarometer survey
(N = 3,504)
Netherlands 88% U.S.A. survey
Britain 58% (N = 377)

Finland 56%
Austria 55%
Germany 48%
Source: Harris Interactive Inc.
Belgium 42% (2002, August 8). European
physicians especially in
Italy 37% Sweden, Netherlands and
Ireland 28% Denmark, lead U.S. in use of
electronic medical records.
Greece 17% HealthCare News, 2(16), 1-3.

U.S. 17% European Union Barometer

June, July 2001 (numbers
Spain 9% repercentaged by Harris
Interactive) and Harris
France 6% Interactive Surveys for U.S.A. in
Portugal 5% June 2001 and January /
February 2001.
Care Management Processes in
Physician Organizations (N = 1,040)
Process Diabetes Asthma CHF
1. Case management 39.7 39.7 43.4

2. Feedback to 24.1 24.1 30.5

physicians
3. Disease registries 31.2 31.2 34.8

4. Clinical guidelines 33.9 33.9 27.7

with reminders
Mean 33.2 32.2 34.1

Practices using all 4 12.7 7.6% 8.6

Casalino, L. et al. (2003). External incentives, information technology, and organized

processes to improve health care quality for patients with chronic diseases. Journal of the
American Medical Association.
 Chronic Care Management
Overarching Goal

Improved Health Status

 Regular visits with health

providers
 Focus on function
 Prevent exacerbations and
complications
 Emphasizes self-management
 Ensures access to services
proven to improve outcomes
 Establishes links through time
with information systems
 Follow-up initiated by medical
provider
In Summary

 Chronic care management

offers improved health status
for many with chronic diseases

 Chronic illness care should be

based on the best available
evidence

 Need consistent quality

measures and additional
research in the various models
 TERIMA KASIH