Chronic disease management plan conditions

As primary care physicians, we spend the majority of our time caring for patients with chronic diseases, but data suggest we achieve the standard of care for chronic diseases and preventive care only 50 percent to 60 percent of the time. 1

We should not be surprised by these results. It takes time to measure and monitor our patients' progress, and time is something we have far too little of. Years of declining payment have necessitated that we see more patients in less time. Having adequate time to listen and examine the patient is now a luxury. Proper documentation and coding, past record review, and testing follow-up consume most of our time between visits.

Four years ago our family medicine residency program decided to look closely at our chronic disease care performance. We provide 32,000 patient visits per year at our urban Milwaukee practice, where most patients are underserved and many have chronic medical conditions. When we developed functional patient registries and were able to produce the data we needed for our assessment, we realized that our performance was no better than average. We knew we could do better, but not without an organized, team-based approach. The outdated model where all the responsibility for patient care lies with the physician was not working. We decided to make improving chronic disease management our No. 1 goal. After much research we began to implement the components of the chronic care model, an approach that combines delivery system redesign, enhanced use of technology for real-time decision making and patient self-management support to produce more productive interactions and thus better outcomes. 2

This article describes our experience, focusing primarily on how we developed and use teams to improve chronic disease care. Much of what we accomplished can and has been replicated in other practice environments. We hope you will learn from and be encouraged by our experience.

Getting buy-in

Our work began by seeking commitment from our organization's leaders to support the effort. Our organization, like most others, is skeptical of any change that may increase expenses or reduce revenue. Since the chronic care model requires new duties of all office personnel, including providers, short-term revenue loss was possible. A key selling point was that implementing the processes required to improve chronic disease care would also help us become recognized as a patient-centered medical home (PCMH) by the National Committee for Quality Assurance (NCQA), which we have since accomplished, and enable us to negotiate for improved reimbursement. Our organization's leaders recognized that improving chronic disease care using a team-based approach would position us well for the future. Later we realized an increase in patient visits as our care teams identified patients who were behind in recommended monitoring and contacted them for follow-up visits. This gain offset any initial loss of revenue and should encourage practices thinking about changing the way they deliver chronic care.

Next we formed the first of many important teams – a physician, a nurse and an administrative leader to champion our efforts. Their role was to educate themselves on the chronic care model and serve as educators and motivators of the rest of the staff. Without leadership, especially from nursing and administration staff, the process would not have been successful.

Our champions played a vital role in changing the culture of our practice to one focused on patient-centered care, but this shift required the effort of our entire staff. The team organized meetings where the fundamentals of chronic disease management and team-based care were explained to all of us. This education was crucial to understanding the language of the chronic care model, to clearly defining the project goals and to creating an environment in which our efforts could succeed. We held meetings on motivational interviewing, stages of change theory, goal setting, action plan development and patient self-management support. If your practice does not have the resources to provide this type of education, there are good, free educational videos available at a number of web sites, including www.chcf.org (the California Health Care Foundation) and www.improvingchroniccare.org.

Another key to engaging our staff was to start slowly. We began with one small, doable project that required using the registry feature embedded in our electronic health record system (EHR) to track outcomes that could be measured in a short, definable time period (for more information on registries, see “Registries Made Simple”). We knew it would be important to avoid overloading our teams, particularly at the outset, so we focused our resources on high-risk patients, beginning with diabetes patients whose A1Cs were over 9 percent. We assembled our first diabetes care team and piloted our new process before rolling out the program to include others. This helped to streamline the project, build momentum and prevent the kinds of errors in data or process that breed opposition to change, particularly among physicians.