Competency-based Curriculum: Chronic Care Model

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Competency-based Curriculum: Chronic Care Model >  Competency-based Curriculum: Chronic Care Model

Competency-based Curriculum: Chronic Care Model

Last updated at 08/27/2007 10:41:11 AM EST by Traci Nolte
STFM CBC Chronic Care Model
Jeff Susman, MD
 
Introduction
The chronic care model (CCM) is a product of Ed Wagner and the MacColl Institute for Healthcare Innovation, and reflects many years of development, application and assessment. There are six components to the CCM:
1.      Organization of the health care delivery system
2.      Community linkages
3.      Patient self-management support
4.      Decision support
5.      Delivery system design
6.      Clinical information systems

The Chronic Care Model Elements
Self-Management
Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.
 
Decision Support
Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.
 
Delivery System Design
The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.
 
Clinical Information System
A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.
 
Organization of Health Care
Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.
 
Community
To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.
 

Much of the underpinnings and application of the CCM overlap with the core concepts of performance improvement, the new model from the FFM, and other efforts to robustly describe the interactions among the patient, provider and practice, and community. 
 
The CCM has been refined and the core concepts of the model have been applied to many common diseases including diabetes, asthma, congestive heart failure and depression. There is beginning to amass research that demonstrates at least short term improvements in outcomes with systematic application of the CCM (Shojania, JAMA 2006). Many of the CCM concepts can also be applied to preventive health services and even acute illness care. Thus, the CCM provides a robust model for enhancing the care of patients and populations. 
 
The CCM has been the basis for a number of practice, academic (the ACCC) and now community improvement efforts (RWJ Aligning Forces for Quality).    Recent informal evaluations (e.g., early Transformed findings, Ed Wagner comments) and more formal research provides the following insights:
 
  • Changes in practice are difficult to make and sustain
  • The current environment does not substantially value the CCM and many conflicting groups vie for providers attention
  • Large organized systems such as the VA are better positioned to make the investment and develop systems to create a receptive environment for the CCM
  • Strategic and leadership vision and support are important
  • Champion(s) are important to CCM implementation
  • Early adopters have been the first to embrace the model, but most health care professionals have not adopted this approach
  • There need to be better alignment with financial and other incentives
  • Integration between primary and specialty care, and different health care sectors is important
  • Efforts to engage patients and consumers are in their infancy
 
Despite these challenges, the early evidence of successful implementation of the CCM in a variety of environments, suggests that this framework provides a productive and practical guide to performance and quality improvement. 
 
The following instructional unit provides suggestions on learner competencies and approaches to teaching, learning and implementing the CCM. 
 
Goals
            Students by the end of their FM Clerkship
Be familiar with the chronic care model and describe its application to the management of chronic disease
                       
            Residents by graduation
Be able to apply components of the chronic care model within the residency practice to enhance care for chronic disease
 
            Experienced Practicing Physicians
Lead the implementation of the chronic care model within a practice and effectively integrate chronic disease management into continuous performance improvement efforts
 
Link personal self assessment and maintenance of certification efforts with chronic disease management and performance improvement activities
 
Learning objectives
            Students by the end of their FM Clerkship will be able to:
Name the components of the Chronic Care Model
 
Understand the application of evidence based guidelines to the diagnosis and management of chronic disease
 
Describe the application of these components to a model chronic disease (e.g., asthma, diabetes)
 
            Residents by graduation will be able to:
Understand the basic diagnostic and management issues with common chronic diseases including their etiology, risk factors, comorbidities, natural history, and treatment
 
Recognize the socioeconomic impact of the chronic disease on health care spending, overall health care delivery and the utilization of health care resources
 
Accurately assess their model practices’ activities relative to the chronic care model
 
Work with faculty to design and implement the chronic care model for improving the care of a common chronic condition
Begin to link personal knowledge (using the in-training exam), performance in practice (with quality measurement data from their practice), and performance improvement efforts using the chronic care model
 
Be comfortable using the electronic health record and disease management registries
 
Understand information from insurers and P4P efforts including common data flaws and problems
           
            Experienced Practicing Physicians will be able to:
Effectively measure outcomes for chronic disease
 
Create and implement a chronic disease registry
 
Lead multidisciplinary office teams in ongoing improvement efforts to enhance the care of a target disease
 
Systematically assess efforts to enhance chronic disease management, including such problems as asthma, diabetes mellitus, congestive heart failure and depression
 
Link personal self assessment (from use of tools such as recertification exams and MOC activities) with practice assessment (using P4P data and other clinical outcomes data) to devise ongoing improvements in personal and practice improvement
 
Respond effectively to P4P efforts including appropriate appeal of inaccurate information
 
Effectively assess population health and use this data to target chronic conditions in a culturally astute manner
 
Extend the application of the CCM to preventive services and acute care


Learner characteristics
Preassessment methods
            Students at the beginning of their FM Clerkship
                        Test
            Residents upon entry
                        Test
            Experienced clinicians
                        Test
                        Practice Assessment
 
Cultural competency and population health
            Students at the end of their FM Clerkship
            Residents upon graduation
                        Experienced clinicians
 
Teaching and Learning Activities/Instructional Methods & Support Services/Needed Resources
 
            Students during FM Clerkship
Lecture discussion describing the CCM elements
                       
Paper on medical problem that incorporates evidence-based guideline
 
Project to enhance chronic or preventive care in practice
 
Practical experience with EHR, disease registry, elements of CCM on clerkships
 
            Residents
Lecture discussion on CCM
 
Core didactics covering common chronic diseases that integrates EBM, population health, care managment
 
Use of EHR and disease residency in model practice
 
Development of PI project that incorporates elements of CCM including development and use of a disease registry, electronic flow sheets, planned/focused visits, patient empowerment strategies
 
Work with community agencies targeting chronic disease (e.g., AHA, ADA, ACS)
 
            Experienced Clinicians
Facilitated practice assessment
 
Participation in AAFP METRIC or ABFM MOC activity
                       
Participation in AAFP, IHI, or other practice improvement collaborative
 
Participation in IHI, AAFP or other focused conference on practice improvement
 
Work with QIO to enhance care of chronic disease
 
Implement disease registry or other element of CCM/new model of care
 
Respond to P4P data with planned PI intervention using CCM


Learner and Program Evaluation
            Students by the end of their FM Clerkship
                        FM Shelf Exam
 
Percent who on a written or oral exam, when given a common chronic disease, can describe the application of the CCM in all of its components
 
            Residents by graduation
                        FM In-training exam
 
Patient outcomes data including satisfaction
 
Perceived self-efficacy
 
Within the model office setting, percent who can apply knowledge of the CCM to describe a project related to their own or teams’ population of patients
 
Percentage of residents who have had an opportunity to take part in a CCM project
 
Percentage of residents who actually complete CCM project and assess at least short term outcomes
 
 
            Experienced Practicing Physicians
Clinical outcomes data including patient satisfaction, patient safety, efficiency, and other points on the quality compass
 
AQA, PQRI and other P4P data
 
Meet accreditation goals/standards
 
Continuity of care and development of enhanced medical home
 
Faculty Development and Lifelong Learning
            PEP 3 module
 
 
 
Resources
 
Web Resources
Overview of the CCM
 
Application of the CCM to diabetes care
 
Institute for Healthcare Improvement
 
IOM description of application of CCM and health care reform
 
Department of Health Chronic Disease workshop
 
Links to the Academic Chronic Care Collaborative, California Academic Chronic Care Collaborative, Academic Rapid Response Collaborative and the AAMC Institute for Improving Care
 
IHI White Paper on planned care
 
Application of CCM concepts in CHCs
 
RWJ Improving Chronic Illness Care
 
RWJ Aligning Forces for Quality
 
 
 
Articles
Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF.Challenges of Change: A Qualitative Study of Chronic Care Model Implementation. Ann Fam Med. 2006 Jul; 4(4): 317-326.
 
Dietrich AJ, Oxman TE, Williams JW Jr, Kroenke K, Schulberg HC, Bruce M, Barry SL. Going to Scale: Re-Engineering Systems for Primary Care Treatment of Depression. Ann Fam Med. 2004 Jul; 2(4): 301-304.
 
Bodenheimer T. Innovations in primary care in the United States.
BMJ. 2003 Apr 12; 326(7393): 796-799.
 
Blue Ribbon Panel of the Society of General Internal Medicine.
Redesigning the Practice Model for General Internal Medicine. A Proposal for Coordinated Care: A Policy Monograph of the Society of General Internal Medicine. J Gen Intern Med. 2007 Mar; 22(3): 400-409. published online before print February 2, 2007
 
Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006 Jul 26;296(4):427-40.
 
Bodenheimer T. Planned visits to help patients self-manage chronic conditions.
Am Fam Physician. 2005 Oct 15;72(8):1454, 1456
 
 
Mohler PJ, Mohler NB. Improving chronic illness care: lessons learned in a private practice. Fam Pract Manage Nov/Dec 2005.  
 
 
 
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