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The Chronic Care Model: Implications for HIV Care and Training

October 1, 2007Kathleen A. Clanon, MD, FACP

Pacific AETC

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Goals for Talk:

1. Describe the elements of the Chronic Care Model and its rationale.

2. Describe practical applications of the Chronic Care Model in HIV specific settings.

3. List possible training settings and audiences for which Chronic Care Model content might be appropriate.

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The Usual Visit Patient is in the room, chart in the

slot. Nurses and doctors don’t confer. MD reviews the chart for 30 seconds

before entering the room. Patient’s goal is to get a form filled

out; MD is worried about new detectable viral load.

HCM flow sheet is half filled out. MD drones through adherence rant. Patient leaves, MD notes later that

ppd and pap were overdue.

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Evolution of HIV Care

Disease Care AcuteReactiveFocus on dx/rxCustomized careSpiritualMD role central

Health CareChronic Proactive

Focus on behaviorStandardized care

PracticalPt role central

Kathleen Clanon, MD 2007

1980 2010

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Tyranny of the Urgent:

What doesn’t get donewhen we do diseasecare instead of health care?

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Tyranny of the Urgent: What Doesn’t Get Done Adherence counseling Prevention counseling Family planning Nutrition Stress reduction training Mental health Smoking cessation Substance abuse treatment Vaccinations Cancer screening HCV treatment

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Hepatitis A & B Vaccination Practices for Ambulatory Patients with HIV-Infection

82

57

32

17

57

67

23

13

0

20

40

60

80

100

Pat

ient

s (%

)

HBV HAV

Screened Eligible for Vaccine Vaccinated (> 1 dose) Vaccinated (Series)

Methods- 9 Clinic (HOPS) Sites- N = 1071 in study- Analysis of HOPS data base

Design Results

From: Tedalid EM et al. Clin Infect Dis 2004;38:1478-84.

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One Example: Smoking

Many PWHIV smoke (52% vs 23% in gen pop)

Smokers on HAART have morbidity (ADC = 36%) and mortality (53%)compared to nonsmokers.

Well-documented programs and interventions for smoking cessation are available.

Does your clinic have a smoking cessation program for HIV positive patients?

Feldman J Am J Public Health 2006;96(6):1060

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Not Just HIV: Preventive Care Not Just HIV: Preventive Care QualityQuality

Over 4000 patient visits by 138 Over 4000 patient visits by 138 family physiciansfamily physicians

Patients were up to date on Patients were up to date on 55% of routine screening tests55% of routine screening tests 24% of immunizations24% of immunizations 9% of health behavior counseling9% of health behavior counseling

Stange et al. Prev Med 2000;31:167Stange et al. Prev Med 2000;31:167

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Do the MathDo the Math

A primary care physician with a panel of 2500 A primary care physician with a panel of 2500 average patients (not HIV) would need to average patients (not HIV) would need to spend: spend:

7.4 hours per day to do all recommended 7.4 hours per day to do all recommended preventive care.preventive care. [Yarnall et al. Am J Public Health 2003;93:635][Yarnall et al. Am J Public Health 2003;93:635]

10.6 hours per day to do all recommended 10.6 hours per day to do all recommended chronic care.chronic care. [Ostbye et al. Annals of Fam Med 2005;3:209][Ostbye et al. Annals of Fam Med 2005;3:209]

Slide adapted from Bodenheimer.

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Impact of the Aging Epidemic: More Chronic Illnesses

Prevalence of other chronic illnesses in VA patients with HIVHypertension 40%Hyperlipidemia 22%Diabetes 17%

Fultz SL et al, CID 2005 Sep 1; 41:738-43

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HIV Providers’ Comfort Treating Other Chronic Illnesses

Comfortable treating chronic illness

DM HTN Hyper-lipidemia

Depression

General Internists seeing HIV in Gen Med Clinic (n=66)

98% 98% 98% 49%

Gen Internists seeing HIV in ID Clinic (n=33)

61% 79% 73% 42%

ID Specialists in ID Clinics (n=51)

57% 73% 71% 33%

Fultz SL et al, CID 2005 Sep 1; 41:738-43.

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What Do These Data Demonstrate?

Overfocus on the clinician-patient dyad as the unit of care.

Underutilization of the team (esp. the patient) in care.

Insanity of the 15 minute visit.

Slide adapted from Bodenheimer.

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My Favorite Quote from the Government

“Improvements in care cannot be achieved by further stressing current systems of care. The current systems cannot do the job. Trying harder will not work.”

IOM 2001: Crossing the Quality Chasm

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Genesis of the CCM: Why Research Results and Real Life Don’t Match

Rushed practitioners not following established practice guidelines “The gap between knowing and doing.”

Lack of care coordination

Lack of active follow-up to ensure the best outcomes

Patients not trained to manage their own illnesses successfully

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History of the Chronic Care Model

Developing the Model Improving Chronic Illness Care Program, MacColl

Institute for Healthcare Innovation, Seattle. RWJF Chronic Illness Meeting

Developing a Change Strategy IHI Breakthrough Series, Dallas 1999

Disseminating the Practice Model applied with diabetes, geriatrics, asthma, CHF,

CVD, HIV/AIDS, and depression in >500 health care organizations via collaboratives.

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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

Practice Level

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Informed,ActivatedPatient/Client

ProductiveInteractions

Prepared,ProactiveCare Team

Improved Outcomes

Case man.;

Integrate MH care

AETC training; Dissem DHHS

Guidelines

CAREware, labtracker;

Aries

Client advocacy,

peer mentoring

All Parts

Food bank, volunteers, child care.

Community

RWHATMA Continuum of Care

HIV Chronic Care Model

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Domains of the Chronic Care Model

• Self-management Support Patient sets goals and is in charge of care.Education focuses on problem-solving skills.

Peer mentoring and support. Adherence and prevention programs.

• Community InvolvementForm partnerships with ASO’s.

Address stigma and myths.

• Delivery System Design Planned and group visits. Case management.

Integrating mental health/subs abuse/medical care..

Domains of the Chronic Care Model• Decision Support (Provider Knowledge and

Behavior)Embed guidelines into daily care.Share guidelines with patients, case managers

AETC activities

• Clinical Information SystemProvide reminders of care for providers and pts. Feed aggregate data into CQI system.

Share appropriate info between partner orgs.

• Health Care Organization/GranteeEncourage open handling of errors.Support improvement at all levels of the org.

Set and monitor goals in chronic care outcomes for the organization.

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Does the CCM Improve Outcomes?

It’s a model, not a single intervention.

Meta-analysis of 112 studies of four chronic illnesses: asthma, CHF, Type II DM, and depression.

“Interventions with at least one CCM element had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied.”

Tsai, A.C. et al “A meta-analysis of interventions to improve care for chronic illnesses.” AJ Managed Care 8/05

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HIV: Why Might the CCM Work?

Dangerous chronic illness with available, effective treatment.

Treatment is difficult and lasts over years and decades.

Treatment requires sustained behavior change on part of patient.

Gap between knowledge and outcomes.

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CCM in Action: Two Dimensions

Patient Self-Management Delivery System Design

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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

Practice Level

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Patient Self-Management

Goal setting

Assessing conviction and confidence

Action planning

Peer mentoring and advocacy

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Can “Our Patients” Self-Manage?

“Patients with chronic conditions self-manage their illness. This fact is inescapable. Each day, patients decide what they are going to eat, whether they will exercise, and to what extent they will consume prescribed medications.”

Bodenheimer, et al 2002 JAMA 288(19); 2470

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Traditional Patient Education vs.Self-Management Education

Traditional Patient Education

Self-Management Education

Content TaughtDisease-specific information and technical skills

Problem-solving skills that can be applied to chronic conditions in general

Definition of the problem

Inadequate control of disease

Patient formulates the problem which may/may not be directly related to disease

Theoretical construct underlying the education

Disease-specific knowledge produces behavior change and leads to improved clinical outcomes

Patient’s self-efficacy (learned through setting short-term action plans) leads to improved clinical outcomes

GoalCompliance with behavior changes taught to patient to improve clinical outcomes

Increased self-efficacy to improve clinical outcomes

Educator Health professionalHealth professional or peer leader and other patients in the group

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Action Plan (Example)

1. Goals: Something you WANT to do: Begin exercising_______

2. Describe: How: Walking________ Where: Around the block What: 2 times Frequency: 4 x/wk When: After dinner____

3. Barriers: Have to clean up; bad weather

4. Plans to overcome barriers: Ask kids to help; get rain gear

5. Conviction 8 & Confidence 7 ratings (0-10)

6. Follow-Up: Next visit – 2 months

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Delivery System Design

Planned visits Expanding staff roles

Using information systems

Group visits

Case management

Integrated care: One-stop-shop

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Planned Medical Visits

“an encounter… that focuses on overall patient goals and other aspects of care that are not usually delivered during an acute-care visit.”

AAFP, June 2005

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Planned Medical Visits “Standing meeting” of staff (no chairs,

no donuts) at beginning of day to review each patient

Team members are alerted and on the same page (adherence educators, case managers, etc.) Tasks are shared.

Print out of what HCM the pt needs is on the front of the chart with overdue items flagged.

Materials are in room(vaccines, pap materials, forms and education materials).

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Using Staff Differently

May be peers, health educators, M.A.s. They take the lead on health promotion.

Meet with pts pre-, during-, or post- the clinician visit.

Advantages are: Patients connect with staff differently

than with M.D. Cheaper staff can take more time with

pts. Staff like it!

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Group Visits

Medical visits, scheduled for 2.5 hours. 10-12 patients scheduled. Clinician, case managers, adherence

educators, benefits advisers all present.

Starts with education, group questions. Focus on self-management, prevention and HCM.

Providers pull pts out for brief one-on-ones as group session continues.

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Implementing the CCM: What Are the Barriers?

Time

Turf

Trust

Turnover

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Implementing the CCM: What Are the Barriers?

Payers may not reimburse for group work or prep work

Difficulty of changing big systems

HIPAA

Tradition of individualism in medicine. (We are the biggest obstacle.)

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What Are the HIV-specific Barriers?

Stigma and disclosure concerns

No patient-accessible measure of daily health (similar to glucose or peak flow)

Groups most affected by HIV have social, educational challenges

Our pts deal with chaos; low show rates and crises mean staff need to be consistent and protect the planned visit time.

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Resources

Websites: www.improvingchroniccare.org www.collaborativeselfmanagement.org www.nqc.org

Contacts: Kathleen A. Clanon, MD, FACP

kclanon@jba-cht.com