How
to Make Systems Changes
for Improved Care
Chronic
Care Model
This model provides an organizational approach to caring for people
with chronic disease in a primary care setting. The system is population-based
and creates practical, supportive, evidenced-based interactions
between an informed, activated patient and a prepared, proactive
practice team. The Chronic Care Model summarizes the basic elements
for improving care in health systems at the community, organization,
practice and patient levels for chronic illnesses such as diabetes.
The model is based on available literature about promising strategies
for chronic illness management. The model was refined during a planning project
supported by the Robert Wood Johnson Foundation, and revised with
input from a large panel of national experts.
4
Permission is granted to reproduce this figure and written material
for educational use. Original source is Wagner, EH. Effective
Clinical Practice 1998;1:2-4.
A
complete description of the
components of the model is available at the Improving Chronic Illness
Care website (www.improvingchroniccare.org).
To achieve improved clinical outcomes it is necessary to develop
and utilize:
Clinical
Practice Recommendations.
Change concepts are ideas that have been found to be useful in developing
specific improvement activities (e.g., all patients with diabetes
should have A1C regularly assessed). Clinical practice recommendations
summarize change concepts for disease states. Clinical practice
recommendations for diabetes care are available from the American
Diabetes Association (click here
or go to resources) and other professional organizations. However,
in order to achieve acceptance and use of the guideline it is often
necessary to develop local clinical practice recommendations.5
The process for local development is outlined in the following table.
Guidelines require ongoing review and updating.
6
Guideline
Development Process |
1.
Put together your guideline development team:
- Clinical champion
- Administrative leader
- Day-to-day leader -
Technical expert |
2.
Compile published guidelines. |
3.
Supplement with recent reviews:
Written after or not
included in the published guidelines. |
4. Conduct a focused literature review. |
5.
Customize the guideline for your facility to
promote ownership. |
6. Develop tools/mechanisms to assist implementation:
Standing orders, reminder
systems, system changes. |
7.
Educate Providers:
Academic detailing. |
8.
Monitor implementation and adherence:
PDSA cycles (see
Model for Improvement). |
9.
Fine tune guideline continuously:
Update from the
Medical literature.
Modify on the basis local use.
|
10.
Conduct regular review of guideline:
Work of the
guideline committee just begins with the
distribution of the guideline.
|
Note |
In
order to achieve acceptance and use of a guideline it is often
necessary to develop local clinical practice recommendations. |
Productive
Interactions.
The elements of good chronic illness care require productive clinical
interactions between informed activated patients and prepared proactive
practice teams. An informed activated patient understands the disease
process, and realizes his/her role as the daily self-manager. The
proactive team members have the patient information, decision support,
people, equipment, and time required to deliver evidence-based clinical
management and self-management support at the time of the visit.
A thorough assessment is conducted and clinical management is guided
by tailoring clinical management protocols to the needs and preferences
of the patient. As a result of their interaction a shared care plan
is developed including goal setting and problem solving. Active,
sustained followed up ensures progress toward meeting the goals
and amending management to meet them.
Note |
The
elements of good chronic illness care require productive clinical
interactions between informed activated patients and prepared
proactive practice teams. |
Support
from the health system and the community is necessary to facilitate
the productive interaction between patients and providers. The key
elements required from them include:
- Health
Care Organization
-
Goals for chronic illnesses are a measurable part of the organization's
annual business plan.
-
Benefits that health plans provide are designed to promote
good chronic illness care.
- Provider
incentives are designed to improve chronic illness care.
-
Improvement strategies that are known to be effective are
used to achieve comprehensive system change.
-
Senior leaders visibly support improvement in chronic illness
care.
- Community
Resources and Policies
-
Effective programs are identified and patients are encouraged
to participate.
-
Partnerships with community organizations are formed to develop
evidence-based programs and health policies that support chronic
care.
-
Health plans coordinate chronic illness guidelines, measures
and care resources throughout the community.
Specific
elements within health care organizations for proper chronic illness
care include:
-
Self-management Support
-
Providers emphasize the patient's active and central
role in managing their illness.
-
Standardized patient assessments include self-management knowledge,
skills, confidence, supports, and barriers.
-
Effective behavior change interventions and ongoing support
with peers or professionals are provided.
-
Collaborative care planning and assistance with problem solving
are assured by the care team.
- Decision
Support
-
Evidence based guidelines are embedded into daily clinical
practice.
- Specialist
expertise is integrated into primary care.
-
Provider education modalities proven to change practice behavior
are utilized.
-
Patients are informed of guidelines pertinent to their care.
- Delivery
System Design
-
Team roles are defined and tasks delegated.
-
Planned visits are used to provide care.
-
Continuity is assured by the primary care team.
-
Regular follow-up is ensured.
- Clinical
Information Systems
-
There is a registry with clinically useful and timely information.
-
Care reminders and feedback for providers and patients are
built into the information system.
-
Relevant patient subgroups can be identified for proactive
care.
-
Individual patient care planning is facilitated by the information
system.
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Continue to
PDSA Cycle Model |
|