La gestión de los cuidados a enfermos crónicos:La gestión de los cuidados a enfermos crónicos:experiencias en EEUUexperiencias en EEUU

Caring for people with chronic illness:Caring for people with chronic illness:lessons from the United Stateslessons from the United States

Thomas Bodenheimer, MDThomas Bodenheimer, MDProfessor, Department of Family & Community MedicineProfessor, Department of Family & Community Medicine

University of California, San Francisco, USAUniversity of California, San Francisco, USA

% of People in US with a Chronic Illness

45%57%

1 Chronic Illness

43% 2 or more chronic illnesses

Hoffman et al, JAMA 1996;276:1473Hoffman et al, JAMA 1996;276:1473

56 million people56 million peopleSpain: 47 millionSpain: 47 million

Per capita health expenditures, 2008Per capita health expenditures, 2008

OECD, 2010OECD, 2010

$2,902

$7,538

Spain US

9% of GDP9% of GDP 16% of GDP16% of GDP

Average per capita spending by Average per capita spending by number of chronic conditions (2004)number of chronic conditions (2004)

$994$2,753

$5,062$7,381

$10,091

$16,819

$0$2,000$4,000$6,000$8,000

$10,000$12,000$14,000$16,000$18,000

0 1 2 3 4 5+

Number of chronic conditions

Anderson, “Chronic conditions” Johns Hopkins, 2007Anderson, “Chronic conditions” Johns Hopkins, 2007

If the US is spending so much, If the US is spending so much, we must be doing a great jobwe must be doing a great job

27% of discharged CHF patients 27% of discharged CHF patients are readmitted within 30 daysare readmitted within 30 days [Jencks [Jencks et al. NEJM 2009;360:1418]et al. NEJM 2009;360:1418]

35% of eligible atrial fibrillation patients 35% of eligible atrial fibrillation patients failed to receive warfarin failed to receive warfarin [Piccini et al. Am J [Piccini et al. Am J Coll Cardiol 2009;54:1280]Coll Cardiol 2009;54:1280]

Only 15% of smokers are offered Only 15% of smokers are offered assistance to quitassistance to quit [Unrod et al. JGIM [Unrod et al. JGIM 2007;22:478]2007;22:478]

US: doing a great job??US: doing a great job??

• 50%50% of people with HBP are poorly controlled of people with HBP are poorly controlled

• 62%62% with elevated LDL-cholesterol have not with elevated LDL-cholesterol have not reached their LDL goalreached their LDL goal

• 63%63% of people with diabetes have HbA1c >7 of people with diabetes have HbA1c >7

Egan et al. JAMA 2010;303:2043, Afonso et al. Am J Manag Care Egan et al. JAMA 2010;303:2043, Afonso et al. Am J Manag Care 2006;12:589, Saydah et al. JAMA 2004;291:3352006;12:589, Saydah et al. JAMA 2004;291:335

Percent of visits that are primary carePercent of visits that are primary care 2006 2006

79%

72%

83%

66%

71%

76%

67%

0% 20% 40% 60% 80% 100%

HBP

Diabetes

Lipids

CHF

Depression

Asthma

COPD

Chronic care is a Chronic care is a primary careprimary care problem problem

US adult primary care in crisisUS adult primary care in crisis• 9% of medical students choose adult primary care9% of medical students choose adult primary care• Adult primary care shortage: 40,000 physicians by 2020Adult primary care shortage: 40,000 physicians by 2020• Average primary care panel: 2300Average primary care panel: 2300• Primary care physician with panel of 2500 average patients Primary care physician with panel of 2500 average patients

would spend would spend 7.4 hours per day7.4 hours per day doing recommended doing recommended preventive carepreventive care [Yarnall,Am J Pub Health 2003;93:635][Yarnall,Am J Pub Health 2003;93:635]

• Primary care physician with panel of 2500 average patients Primary care physician with panel of 2500 average patients would spend would spend 10.6 hours per day10.6 hours per day doing recommended doing recommended chronic carechronic care [Ostbye et al. Annals of Fam Med 2005;3:209][Ostbye et al. Annals of Fam Med 2005;3:209]

• Primary care with US panel sizes is an impossible jobPrimary care with US panel sizes is an impossible job• Yet great energy and dedication to save and improve Yet great energy and dedication to save and improve

primary careprimary care

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical OutcomesFunctional and Clinical Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care ModelChronic Care Model

Making the Chronic Care Model workMaking the Chronic Care Model work

• We all know the We all know the Chronic Care Chronic Care ModelModel

• But how do we But how do we make it work in the make it work in the stressed primary stressed primary care practice?care practice?

Simplify the Chronic Care ModelSimplify the Chronic Care Model

• Decision supportDecision support• Clinical practice Clinical practice

guidelinesguidelines• Clinician educationClinician education

• Clinical information Clinical information systemssystems• Clinician feedbackClinician feedback• RemindersRemindersRegistriesRegistries

• Delivery system redesignDelivery system redesign• Planned visits Planned visits • Care managementCare managementPrimary care teamsPrimary care teams

• Self-management supportSelf-management support

• SimplifySimplifyRegistriesRegistriesTeamsTeams

RegistriesRegistries• Registries: lists of patients your practice Registries: lists of patients your practice

is responsible foris responsible for• Includes clinical informationIncludes clinical information• Example: diabetes: Example: diabetes:

– Date of last A1c, LDL, blood pressure, eye exam, foot Date of last A1c, LDL, blood pressure, eye exam, foot exam, microalbumin, exam, microalbumin,

– Results of A1c, LDL, blood pressure, etc.Results of A1c, LDL, blood pressure, etc.– What patient education was done?What patient education was done?– Does patient have a goal and plan to achieve that goal?Does patient have a goal and plan to achieve that goal?

• Cochrane review of 5 trials: registries that Cochrane review of 5 trials: registries that identify diabetic patients at risk and bring those identify diabetic patients at risk and bring those patients into care demonstrate reduced HbA1c patients into care demonstrate reduced HbA1c levels compared with usual care.levels compared with usual care. [Griffin, Kinmouth. [Griffin, Kinmouth. Cochrane Library, Issue 3, 2003]Cochrane Library, Issue 3, 2003]

Registries and teamsRegistries and teams• A registry is useless unless someone A registry is useless unless someone

repeatedly and compulsively uses itrepeatedly and compulsively uses it– Searches for care gaps Searches for care gaps – Tries to close the care gapsTries to close the care gaps

• Care gap = deficiencia en atencion medicaCare gap = deficiencia en atencion medica– Process care gapProcess care gap

• Patient with diabetes: no HbA1c for 1 yearPatient with diabetes: no HbA1c for 1 year• 60 year old woman: no mammogram for 5 years60 year old woman: no mammogram for 5 years

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

• Requires a Requires a teamteam to do this work to do this work

Registries and teamsRegistries and teams

• Implementing Chronic Care Model in Implementing Chronic Care Model in primary care must be simpleprimary care must be simple

• Key components: registry and teamKey components: registry and team• For registry to work you need a teamFor registry to work you need a team• Therefore: implementing the Chronic Care Therefore: implementing the Chronic Care

Model = teamModel = team• Team is critical because of primary care Team is critical because of primary care

physician shortage and time it takes to physician shortage and time it takes to provide good chronic and preventive careprovide good chronic and preventive care

• If you have a team, you can provide If you have a team, you can provide excellent chronic careexcellent chronic care

• If you don’t have a team, you can’tIf you don’t have a team, you can’t

It all starts with teamsIt all starts with teams

Creating a team cultureCreating a team culture

• From From II to to WeWe: : – From the lone doctor with “helpers” to From the lone doctor with “helpers” to

the high-functioning teamthe high-functioning team– From From mymy patients to patients to ourour patients patients

Teamwork (trabajo en equipo)Teamwork (trabajo en equipo)

• Large teams (equipos) are difficultLarge teams (equipos) are difficult• Energy and time spent with many team members having Energy and time spent with many team members having

to communicate information and coordinate tasksto communicate information and coordinate tasks• If one person is not cooperative, the entire team can failIf one person is not cooperative, the entire team can fail• ““The best team size is a team of one.” Dr. Harold Wise, The best team size is a team of one.” Dr. Harold Wise,

Making Health Teams Work,Making Health Teams Work, 1974 1974• Smaller teams (teamlets = equipitos) are easierSmaller teams (teamlets = equipitos) are easier

• Divide the practice into small 2-person teams (teamlets) Divide the practice into small 2-person teams (teamlets) • Each teamlet responsible for a panel of patientsEach teamlet responsible for a panel of patients• Same 2 people always work together, patients know Same 2 people always work together, patients know

them and they know the patientsthem and they know the patients• Patients learn to trust the teamletPatients learn to trust the teamletBodenheimer and Laing, Ann Fam Med 2007;5:457;Bodenheimer and Laing, Ann Fam Med 2007;5:457; Bodenheimer T. Bodenheimer T.

Building Teams in Primary CareBuilding Teams in Primary Care, Parts 1 and 2. California HealthCare , Parts 1 and 2. California HealthCare Foundation, 2007.Foundation, 2007. www.chcf.org

Physician/MAPhysician/MAteamletteamlet

PatientPatientpanelpanel

Physician/MA/Physician/MA/teamletteamlet

Patient Patient panelpanel

Nurse, social worker, pharmacist, Nurse, social worker, pharmacist, health educator, nutritionist, receptionisthealth educator, nutritionist, receptionist

Patient Patient panelpanel

Physician/MAPhysician/MAteamletteamlet

1 team, 3 teamlets1 team, 3 teamlets

Two modelsTwo models• The The II (Yo)(Yo) Model: Model:

– Physician orders nurses, medical assistants to Physician orders nurses, medical assistants to do do taskstasks

– May create resentment in team: not my job, I May create resentment in team: not my job, I work for the patients, not for the doctorswork for the patients, not for the doctors

• The The We (Nosotros)We (Nosotros) Model: Model:

– Entire team is responsible for health of our panelEntire team is responsible for health of our panel– Different people on the team have different Different people on the team have different

responsibilitiesresponsibilities– Re-distributing work is not delegating Re-distributing work is not delegating taskstasks from from

physicians to other team members; it is sharing physicians to other team members; it is sharing responsibilitiesresponsibilities

Physician, Physician, MA, NurseMA, Nurse

PatientPatientpanelpanel

PhysicianPhysician

Patient Patient panelpanel

MAMA

TasksTasks

YoYo model model NosotrosNosotros model model

NurseNurse

TasksTasks

Stratify your patients with chronic illnessStratify your patients with chronic illness

• Each teamlet is responsible for a panel of Each teamlet is responsible for a panel of patients. Different patients have different needspatients. Different patients have different needs Routine chronic and preventive services: Routine chronic and preventive services:

medical assistant doing medical assistant doing panel managementpanel management One or two chronic conditions: nurse One or two chronic conditions: nurse

working with medical assistant doing working with medical assistant doing health health coachingcoaching

Multiple illnesses and complex healthcare Multiple illnesses and complex healthcare needs: doctor with nurse doing needs: doctor with nurse doing complex complex care managementcare management

3 chronic care functions of 3 chronic care functions of primary care teamprimary care team

• Panel managementPanel management: making sure every : making sure every patient with a chronic condition has all their patient with a chronic condition has all their evidence-based care done on timeevidence-based care done on time

• Health coachingHealth coaching: making sure every patient : making sure every patient with a chronic condition understand their with a chronic condition understand their disease, is assisted with healthy behavior disease, is assisted with healthy behavior change and medication adherencechange and medication adherence

• Complex care managementComplex care management: intensive : intensive management of high-cost patients with management of high-cost patients with multiple chronic conditionsmultiple chronic conditions

Panel managementPanel management• For patients needing routine preventive and chronic For patients needing routine preventive and chronic

carecare• Cannot work without a registry; the registry identifies Cannot work without a registry; the registry identifies

care gapscare gaps• One team member is given One team member is given protected timeprotected time to be panel to be panel

manager -- repeatedly review registry, contact patients manager -- repeatedly review registry, contact patients needing preventive/chronic careneeding preventive/chronic care

• Panel manager works with standing orders/protocols Panel manager works with standing orders/protocols written by physicianswritten by physicians

• Frees up physician for diagnosis, complex patients, Frees up physician for diagnosis, complex patients, care coordination, leading/mentoring the teamcare coordination, leading/mentoring the team

Individual care to population careIndividual care to population care

• Instead of: “what can Instead of: “what can II do to maximize the do to maximize the care of the 25 patients on my schedule care of the 25 patients on my schedule today?”today?”

• The future: “what can The future: “what can wewe do today to do today to maximize the care of the 1500 patients in our maximize the care of the 1500 patients in our panel?”panel?”

Monday Patients

8:00AM Mr. Flores

8:15AM Ms. Jones

8:30AM Ms. Rogers

8:45AM Mr. Johnson

24

Panel management: out-reachPanel management: out-reach• Calling or writing letters to patients with care gaps Calling or writing letters to patients with care gaps

(deficiencias de atencion medica)(deficiencias de atencion medica)• StudyStudy

– Patients with diabetes receiving out-reach letters based Patients with diabetes receiving out-reach letters based on working the diabetes registry on working the diabetes registry

– Had improved HbA1c and LDL levelsHad improved HbA1c and LDL levels– Compared to patients whose physicians reviewed the Compared to patients whose physicians reviewed the

registry and were allowed to decide for themselves how registry and were allowed to decide for themselves how to follow-upto follow-up

• KaiserPermanente: “If you really want something done, KaiserPermanente: “If you really want something done, take it away from the doctors”take it away from the doctors”

Stroebel et al. Joint Commission J Qual Improve 2002;28:441Stroebel et al. Joint Commission J Qual Improve 2002;28:441

Panel management: in-reachPanel management: in-reach

• In-reach means closing care gaps for patients who come to the primary care practice

• Requires electronic list of the care gaps • Medical assistants or nurses look at the list and close the

care gaps. If patient overdue for mammogram, they order the mammogram. Don’t wait for the doctor

• Research study: – Medical assistants reviewed patients’ colorectal cancer

screening status from electronic medical record (EMR) – For patients without colonoscopy, MAs did patient

education, entered referral into EMR– Rate of colonoscopy referrals increased by 123% over

baseline– Educating and reminding physicians did not work

Baker et al, Qual & Safety in Heath Care 2009;18:355

Panel management: in-reachPanel management: in-reach

• Kaiser Permanente’s (KP) Southern California Kaiser Permanente’s (KP) Southern California region initiated panel management in-reachregion initiated panel management in-reach

• Every time a KP member comes to a KP facility, the Every time a KP member comes to a KP facility, the MA reviews the EMR for care gaps and orders MA reviews the EMR for care gaps and orders whatever is needed to close the care gapwhatever is needed to close the care gap

• Improvements in HbA1c and LDL screening, flu Improvements in HbA1c and LDL screening, flu shots, mammograms, Paps, diabetes eye exams, shots, mammograms, Paps, diabetes eye exams, smoking cessation counseling, colorectal cancer smoking cessation counseling, colorectal cancer screening, control of blood pressurescreening, control of blood pressure

Kanter et al, The Permanente Journal 2010;14:38Kanter et al, The Permanente Journal 2010;14:38

3 chronic care functions of 3 chronic care functions of primary care teamprimary care team

• Panel management: making sure every Panel management: making sure every patient with a chronic condition has all their patient with a chronic condition has all their evidence-based care done on timeevidence-based care done on time

Health coachingHealth coaching: making sure every patient : making sure every patient with a chronic condition understand their with a chronic condition understand their disease, is assisted with healthy behavior disease, is assisted with healthy behavior change and medication adherencechange and medication adherence

• Complex care management: intensive Complex care management: intensive management of high-cost patients with management of high-cost patients with multiple chronic conditionsmultiple chronic conditions

Health coachingHealth coaching

• Nurses, medical assistants, community Nurses, medical assistants, community health workers, health educators, and health workers, health educators, and patients can be trained as health coaches patients can be trained as health coaches (promotoras)(promotoras)

• Main tasks: Main tasks: – Make sure patient understands what happened in the visit Make sure patient understands what happened in the visit

(50% of patients do not understand)(50% of patients do not understand)– Make sure patient agrees with the physician’s care plan Make sure patient agrees with the physician’s care plan

(90% are never asked if they agree)(90% are never asked if they agree)– Assist patients with setting goals for lifestyle changesAssist patients with setting goals for lifestyle changes– Make sure patients understand their medications and take Make sure patients understand their medications and take

their medicationstheir medications

Physician and health coach (promotora) Physician and health coach (promotora) meet with patientmeet with patient

Health coachingHealth coaching

• Teamlets with trained medical assistant health Teamlets with trained medical assistant health coaches paired with family physicians coaches paired with family physicians significantly improved smoking and BMI (body significantly improved smoking and BMI (body mass index) documentation, more behavior-mass index) documentation, more behavior-change action plans done, and more LDL testing change action plans done, and more LDL testing compared with comparison groupcompared with comparison group

• Teamlet patients had better A1c, LDL, blood Teamlet patients had better A1c, LDL, blood pressure vs. comparison group but not quite pressure vs. comparison group but not quite statistically significantstatistically significant

Chen et al. J Gen Intern Med 2010;25(suppl 4):610Chen et al. J Gen Intern Med 2010;25(suppl 4):610

Goal-setting and action plansGoal-setting and action plans

• Patient with diabetes Patient with diabetes chooses goal: to eat more chooses goal: to eat more healthyhealthy

• Unrealistic action plan: Unrealistic action plan: “ “I will never eat ice cream”I will never eat ice cream”• Realistic action plan: Realistic action plan:

“Instead of eating a bowl of “Instead of eating a bowl of ice cream every night, I will ice cream every night, I will eat half a bowl twice a week. eat half a bowl twice a week. I am 80% sure I can do it.” I am 80% sure I can do it.”

• Follow-up crucial for action Follow-up crucial for action plansplans

Action plansAction plans• A major responsibility of health coaches is A major responsibility of health coaches is

to engage patients in behavior-change to engage patients in behavior-change action plansaction plans

• Study:Study:– Patients with diabetes who made action plans Patients with diabetes who made action plans

had a reduction in HbA1c (8.9 to 8.0) compared had a reduction in HbA1c (8.9 to 8.0) compared with patients receiving education without action with patients receiving education without action plans (HbA1c 8.7 to 8.7) plans (HbA1c 8.7 to 8.7)

– The improvement was maintained 1 year after The improvement was maintained 1 year after the action plans were donethe action plans were done

Naik et al. Arch Intern Med 2011;171:453Naik et al. Arch Intern Med 2011;171:453

Medical assistants as health coachesMedical assistants as health coaches

• Patients with depression cared for by a medical Patients with depression cared for by a medical assistant/physician teamlet had significantly assistant/physician teamlet had significantly better outcomes (lower PHQ-9 scores) than better outcomes (lower PHQ-9 scores) than patients cared for by physicians alonepatients cared for by physicians alone

• The medical assistants feltThe medical assistants felt – More professional enrichment from the new More professional enrichment from the new

role role – Comfortable with the new roleComfortable with the new role

Gensichen et al. Ann Intern Med 2009;151:369, Gensichen et al, Gensichen et al. Ann Intern Med 2009;151:369, Gensichen et al, Ann Fam Med 2009;7:513Ann Fam Med 2009;7:513

Health coach doing Health coach doing medication education medication education

3 chronic care functions of 3 chronic care functions of primary care teamprimary care team

• Panel management: making sure every Panel management: making sure every patient with a chronic condition has all their patient with a chronic condition has all their evidence-based care done on timeevidence-based care done on time

• Health coaching: making sure every patient Health coaching: making sure every patient with a chronic condition understand their with a chronic condition understand their disease, is assisted with healthy behavior disease, is assisted with healthy behavior change and medication adherencechange and medication adherence

Complex care managementComplex care management: intensive : intensive management of high-cost patients with management of high-cost patients with multiple chronic conditionsmultiple chronic conditions

Average per capita spending by Average per capita spending by number of chronic conditions (2004)number of chronic conditions (2004)

$994$2,753

$5,062$7,381

$10,091

$16,819

$0$2,000$4,000$6,000$8,000

$10,000$12,000$14,000$16,000$18,000

0 1 2 3 4 5+

Number of chronic conditions

Anderson, “Chronic conditions” Johns Hopkins, 2007Anderson, “Chronic conditions” Johns Hopkins, 2007

Complex care managementComplex care management

• Panel management, health coaching: not for patients Panel management, health coaching: not for patients with complex healthcare needs/high costswith complex healthcare needs/high costs

• Nurse care management is needed, with intensive Nurse care management is needed, with intensive nursing individualized to each patientnursing individualized to each patient

• Nurse complex care managers work with physicians, Nurse complex care managers work with physicians, pharmacists, social workerspharmacists, social workers

• Studies: complex care management improves care Studies: complex care management improves care and may reduce costs for patients with complex and may reduce costs for patients with complex healthcare needshealthcare needs

• Reduces physician time with complex patients Reduces physician time with complex patients

Bodenheimer and Berry-Millett, Care Management of Patients with Complex Healthcare Needs, Robert Wood Johnson Foundation, 2009 (www.rwjf.org/pr/synthesis.jsp)

Complex care managementComplex care management

Geriatric Resources for Assessment and Care of Geriatric Resources for Assessment and Care of Elders (GRACE) (Elders (GRACE) (Indiana University Medical School)Indiana University Medical School)– Nurse practitioner/social worker care manager Nurse practitioner/social worker care manager

team working with primary care physician and team working with primary care physician and geriatriciangeriatrician

– In-clinic, home and phone contactsIn-clinic, home and phone contacts– Extensive training of care manager teamExtensive training of care manager team– Small case load (100-120) for care manager Small case load (100-120) for care manager

teamteam– Higher-risk subgroup had significantly lower Higher-risk subgroup had significantly lower

hospitalization rate than higher-risk usual care hospitalization rate than higher-risk usual care patientspatients

Counsell et al, JAMA 2007;298:2623Counsell et al, JAMA 2007;298:2623

Complex care managementComplex care management

Care Management Plus Care Management Plus (Intermountain Health Care in Utah)(Intermountain Health Care in Utah)

– Extensive training of care manager nursesExtensive training of care manager nurses– Care managers work with primary care teamCare managers work with primary care team– Clinic visits, home visits, phone callsClinic visits, home visits, phone calls– In the higher-risk subgroup, hospital In the higher-risk subgroup, hospital

admissions significantly lower in care managed admissions significantly lower in care managed groupgroup

Dorr et al, JAGS 2008;56:2195Dorr et al, JAGS 2008;56:2195

Complex care managementComplex care management

Guided Care Guided Care (Johns Hopkins)(Johns Hopkins)

– Extensively trained RN care managers work with Extensively trained RN care managers work with primary care team, case loads about 50primary care team, case loads about 50

– Clinic visits, home visits, phone callsClinic visits, home visits, phone calls– RNs teach patients/families self-management RNs teach patients/families self-management

skills including early identification of symptom skills including early identification of symptom worseningworsening

– Improved several quality measuresImproved several quality measures– No reduction in ED visit or hospital daysNo reduction in ED visit or hospital days

Boult et al, Arch Intern Med 2011;171:460Boult et al. Guided Care (Springer Publishing Co, 2009)

Hospital to home care managementHospital to home care management

• Mary Naylor’s model Mary Naylor’s model (Univ of Pennsylvania)(Univ of Pennsylvania)

• Nurse practitioners work with patients Nurse practitioners work with patients during hospitalization and post-hospital at during hospitalization and post-hospital at home with at least 8 home visits and home with at least 8 home visits and phone contactphone contact

• Extensive care manager trainingExtensive care manager training• Reduced hospital and emergency Reduced hospital and emergency

department utilization compared to department utilization compared to controls, with 38% total cost reductioncontrols, with 38% total cost reduction

Naylor et al. JAGS 2004;52:675Naylor et al. JAGS 2004;52:675

Hospital to home care managementHospital to home care management

• Care Transitions Intervention: Eric Coleman’s model Care Transitions Intervention: Eric Coleman’s model (University of Colorado)(University of Colorado)

• Nurses trained as “transition coaches” to teach Nurses trained as “transition coaches” to teach patients/families skills to care for themselvespatients/families skills to care for themselves

• 1 hospital visit, 1 home visit post-discharge, 3 post-1 hospital visit, 1 home visit post-discharge, 3 post-discharge phone callsdischarge phone calls

• Significantly lower readmission rates and lower Significantly lower readmission rates and lower hospital costs compared with controlshospital costs compared with controls

• Less intensive intervention than Mary Naylor’s Less intensive intervention than Mary Naylor’s modelmodel

Coleman et al, Arch Intern Med 2006;166:1822Coleman et al, Arch Intern Med 2006;166:1822

Complex care managementComplex care management• Initial long meeting of patient/family with care team Initial long meeting of patient/family with care team

(physician, nurse, social worker, pharmacist)(physician, nurse, social worker, pharmacist)• Care plan made with team and patient/familyCare plan made with team and patient/family• Nurse care manager responsible for implementing and Nurse care manager responsible for implementing and

assessing care plan, teaching about meds, red flagsassessing care plan, teaching about meds, red flags• Nurse does phone, home-visit f/u, consults with Nurse does phone, home-visit f/u, consults with

physician/teamphysician/team• Regular team meetingsRegular team meetings• Case load 50-70 patientsCase load 50-70 patients• Will not work unless panel management and health Will not work unless panel management and health

coaching are implemented to give physician time for coaching are implemented to give physician time for complex patientscomplex patients

Clinica Family Health Services -- Colorado Clinica Family Health Services -- Colorado (Clinica Campesina)(Clinica Campesina)

• Most patients poor, speak only SpanishMost patients poor, speak only Spanish• Patients almost always see same teamlet Patients almost always see same teamlet

(clinician and medical assistant)(clinician and medical assistant)• 3 teamlets within larger team including nurse, 3 teamlets within larger team including nurse,

health coach (promotora), behavioral health health coach (promotora), behavioral health professional. All team members in same room professional. All team members in same room

• Medical assistants do panel management Medical assistants do panel management • Health coach: patient education, goal-setting/ Health coach: patient education, goal-setting/

action plans for patients with chronic illnessaction plans for patients with chronic illness• Clinica is starting complex care managementClinica is starting complex care management

Co-location of teamCo-location of team

• Picture of the co location

Patients get “tarjeta de visita” with Patients get “tarjeta de visita” with names of their teamletnames of their teamlet

Teamlet discussing a patientTeamlet discussing a patient

Primary care revolution in the USPrimary care revolution in the US

• Many primary care practices are Many primary care practices are initiating team care for patients initiating team care for patients with chronic illnesswith chronic illness– Large systems (Kaiser Permanente) Large systems (Kaiser Permanente) – Community health centersCommunity health centers

• Small private practices are slowly Small private practices are slowly joiningjoining

• This revolution is called Patient-This revolution is called Patient-Centered Medical HomeCentered Medical Home

• We have many challenges but are We have many challenges but are determined to succeeddetermined to succeed