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

http://www.mp3crave.com/template/dobe/newstory/Crying%20Baby.jpg

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