Slide 1

Chronic Care in a PCMHJulie Peskoe, PCDC

Dr. Shondra Williams, Jefferson Community Health Center

Slide 2

Building Blocks of High Performing Primary Care Consistent with CCM

Slide 3

Chronic Disease Care

• Chronic conditions such as diabetes, depression, asthma and cardiovascular disease are the major cause of illness, disability, and death in the United States today.

• In 2010, the medical costs of chronic disease amounted to 75% of healthcare spending.

Slide 4

Percent of types of visits seen in primary care nationwide-2006

From Thomas Bodenheimer-Caring for People with Chronic Illness presentation

Chronic Care is a Primary Care problem

Diabetes Mellitus 72%

Depression 71%

COPD 67%

Asthma 76%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Slide 5

Traditional Delivery system

• Responds primarily to acute, and urgent healthcare problems• Focus: diagnosis, ruling out serious conditions, and relieving

symptoms.• Less focus: education, prevention and helping patients learn to

care for themselves better.

Slide 6

The Case for Chronic Care Model

• To deliver high-quality chronic care to all our patients in a way that a busy community health center can manage, we need to rethink how we deliver the care

• The Chronic Care Model provides us with a framework for thinking about this, and essential tools to help improve our processes

• In particular, a focus on care teams and use of registries can help you get started on redesigning your care delivery to better meet the needs of chronically ill patients.

Slide 7

Chronic Care Management• Those with chronic conditions, better served by systematic

approach that emphasizes:• Patient self-management• Care planning with mulit-disciplinary team• Ongoing assessment and follow-up

Slide 8

Key Components of Chronic Care Model

Informed, Activated Patient

Productive Interactions with

Prepared, Proactive Practice Team

Decision Support

Clinical Information Systems

Delivery System Redesign

Self-Management Support

Slide 9

Care Management

• How do we make the Chronic Care Model work in a busy, stressed, community healthcare practice?

Slide 10

Simplify the Chronic Care Modelfrom Thomas Bodenheimer “Caring for People with Chronic Illness” presentation

• Decision support– Clinical practice guidelines – Clinician education

• Clinical information systems – Clinician feedback – Reminders/Alerts Registries

• Delivery system redesign– Planned visits – Care management Primary care teams

• Self-management support

• Simplify Registries Teams

Slide 11

Registries

• Registries: Lists of patients your practice is responsible for that includes clinical information

• Example: diabetes– Date of last A1c, LDL, blood pressure, eye exam, foot exam,

microalbumin– Results of A1c, LDL, blood pressure, etc. – What patient education was done?

Slide 12

Registries and teams • A registry is useless unless someone systematically

manages it!• Care gap = Lack of medical attention/care

Process care gap:• 60 year old woman: no mammogram for 5 years • Patient with diabetes: no HbA1c for 1 year

Outcome care gap:• Patient with diabetes: HbA1c > 9 • Patient with hypertension: Blood pressure 160/95

• Requires a team to do this work

Slide 13

Teams• Large teams are difficult - Smaller teams or teamlets are

easier– Divide the practice into small teams/teamlets– Each teamlet responsible for a panel of patients– Same teams always work together, – Patients know them and they know the patients

• Bodenheimer and Laing, Ann Fam Med 2007;5;457;Bodenheimer T. Building Teams in Primary Care, Parts 1 and 2, California Healthcare Foundation, 2007. www.chcf.org

Slide 14

Three chronic care functions of primary care team

Panel management: Making sure every patient with a chronic condition is identified proactively and has all their evidence based care done on time

Health Coaching: making sure every patient with a chronic condition understands their disease, is assisted with health behavior change and medication adherence

Complex Care management: Intensive management of high risk patients with multiple chronic conditions

Slide 15

Care Manager Role in CCM

• Relatively new job • Defined differently by different people• Ultimately, you have to shape the role to fit your center’s needs,

and the needs of your patient population• Not all patients need care management• The focus of a Care Manager is usually on needs of chronically ill

patients

Slide 16

Care Manager Role in CCM

Care Manager

Registry work/Panel

managementPre-Visit Planning

Planned visits

Health Coaching/Care

Plans

Linking patients to community resources

Coordinating transitions of

care

Provide educational

materials

Slide 17

Care Manager

• Establish what care management tasks need to be routinely completed for the chosen patient population

• Decide who is capable of, or could be trained to perform those tasks• Everyone should work to the “top of their license”• Establish what tasks and/or staff members care manager will

oversee, as opposed to what they will do

Slide 18

Using the care team to expand the 15 minute provider visit

Pre-Visit

Huddles

Agenda Setting

Medication reconciliation

Ordering routine services

History Taking

Visit

Diagnosis and management

Build relationship with

patient

Post-Visit

Soliciting Patient Concerns

Closing the Loop

Goal Setting/Care Plan

Navigating the System

Between Visits

Telephone calls or emails to

patient to see how they are

doing

Health coach or care manager consults with

provider on how patient is doing

Slide 19

System Redesign

• Neither necessary, nor desireable, to launch entire model at one time!

• Use PDSA methodology to test new model

Pre-Visit

Huddles

Agenda Setting

Medication Reconciliation

Ordering routine services

History Taking

Visit

Diagnosis and management

Build relationship with patient

Post-Visit

Soliciting Patient Concerns

Closing the Loop

Goal Setting/Care Plan

Navigating the System

Between Visits

Telephone calls or emails to

patient to see how they are

doing

Health coach or care manager consults with

provider on how patient is doing

Slide 20

From Theory to Practice: Transition to the

PCMH Model

Slide 21

Overview of Jefferson Community Health Care Centers, Inc.

• Established in 2004• Grew from 1-4 clinic locations in 10 years• 2 of 4 locations grew as a result of 2 disasters-Hurricane Katrina &

BP Oil Spill• Serve nearly 14,000 unique patients annually• Nearly a $10m budget• Recognitions: PCMH Level 3-September, 2012 Joint Commission Accreditation-2011

Slide 22

Our Clinical Practice

Corporate Office

Avondale

River Ridge

Lafitte

Marrero

Slide 23

Service Offerings

• Primary Care & Preventive Care• Dental• Specialty Services: Behavioral Health,

Pediatrics, Podiatry, Obstetrics, Gynecology, & Occupational and Environment Medicine

Slide 24

Transition to Care Coordination Beacon Community Identified a Team Lead Team Development Small Groups to conceptualize essential elements Policy Development Collaboration with other Partners to inform policy development Emphasis was focused on Chronic Care Diabetic Huddles Teaching Tool Development Referral into Care Management Team Approach to Healthcare

Slide 25

Our Process…Challenges Successes

By In A1C Control

Staffing Challenges Sustained Results

Transitions Team Development

Resources Communication Improvement

Time Patient Satisfaction

Chronically Ill Patient Population PCMH concepts have translated to enhanced preventive health screenings

Economics of Patient Population*Medication Management

*Cost of Visits*Transportation

Care Coordinator Follow-up

Productivity vs. Financial Partnerships & Coaching

EMR Optimization-MU

Slide 26

Timeline for Transition

January, 2012 September, 2012

March, 2012

Project Champion

was Identified

Slide 27

Major Milestones EMR Optimization

• PCMH-Level 3 Recognition

Clinical Staff are working to the top of their ability

Slide 28

Staff Considerations• Job Descriptions• Salary Requirements• Care Management Role• Care Coordinator Role• Flow Coordinator

Slide 29

Executive Perspective• Supporting the Clinical Leadership• Staffing• EMR Optimization• Scheduling-Open Access• Shifting and Allocating Resources• Balance of Quality vs. Quantity

Slide 30

Challenges with CCM in a CHC• Realities of a busy health center• Change Management• Staff buy in• Limits of EMR• Patient acceptance• Other competing priorities• Cost of delivering care this way•

Slide 31

Questions• How does your organization handle patients with chronic care

management?• Where do you think your organization will be in a year?• What works well? What doesn’t work?• How do you measure and document the work of care teams?• How do you build trust in teams?• How does leadership communicate goals?• How do you make the roles of team members clear and

transparent?• How does payment/revenue affect your organizations

implementation of the chronic care model? What about that 10th building block of high functioning primary care?