leadership for advancing chronic care in challenging environments california chronic care learning...
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Leadership for Advancing Chronic Leadership for Advancing Chronic Care in Challenging EnvironmentsCare in Challenging Environments
California Chronic Care Learning California Chronic Care Learning Communities Initiative CollaborationCommunities Initiative Collaboration
Kevin Grumbach, MDUCSF and SFGH
Institute of Medicine2001
% of People in US with a Chronic Illness
45%57%
1 Chronic Illness
43%
2 or more Chronic Illnesses
Source: C Hoffman et al, JAMA 1996:276:1473
Chronic Illness:Prevalence and Health Costs
75%
45%
0%
10%
20%
30%
40%
50%
60%
70%
80%
% of Pop % of Health Costs
Source: C Hoffman et al, JAMA 1996:276:1473
Chronic Illness:Room for Improvement
• 27% of hypertensives are adequately treated • Half of discharged CHF patients are
readmitted within 90 days • 35% of eligible patients with atrial
fibrillation receive warfarin • 74% of diabetics have uncontrolled blood
pressures, 71% have elevated lipids, and 54% have hemoglobin a1c levels above 7.0
ROOM For Improvement:Reprise CHN
• 30% CHF discharges readmitted within 30 days
• 21% diabetics have hemoglobin a1c > 9.5%
• 57% of children with persistent asthma not on inhaled steroids
System ProblemNeeding Systems Solution
• IOM Redesign Imperatives:– Reengineered care process– Effective use of information technologies– Knowledge and skills management– Development of effective teams– Coordination of care over patient conditions,
services, sites of care over time
The Chronic Care ModelThe Chronic Care Model
• Community Resources
• Health Care Organization
• Delivery System Redesign
• Self-management Support
• Clinical Information Systems
• Decision Support
Does the Chronic Care Model Work?
• Impact on quality of care
• Impact on costs
Business Case for Chronic Care Model
• Depends on payor mix and payment incentives
– Uninsured– Global capitation– MediCal– Medicare
Other Benefits to the Organization
• Treating the chronic ills of safety net culture
– Activated staff– Culture of improvement and problem solving– Change is possible
How can change be created in complex adaptive organizations?
Special Challenges forthe Safety Net
Functional Health Literacy,Diabetic Patients at SFGH
38%
13%
49% InadequateMarginalAdequate
Source: D Schillinger et al, JAMA 2002;288:475
Assets of the Safety Net
• $ Incentives not always completely misaligned
• Systems and organization
• Talent and commitment
The Role of Leadership