Chronic Care Challenges:People, Places, and Principles

David B. Reuben, MDArchstone Foundation Chair and

ProfessorDavid Geffen School of Medicine

at UCLA

Outline of next 15 minutes

• Population-based health care needs• Physicians roles in coordinating care• Meeting population-based health needs• Framework and principles for successful

models

Population-based Health Care

• Who are the elderly Americans?– Not sick + chronic diseases

Population-based Health Care

• Who are the elderly Americans?– Not sick + chronic diseases– Sick, functionally impaired

Population-based Health Care

• Who are the elderly Americans?– Not sick + chronic diseases– Sick, functionally impaired– At the end of life

Population-based Health Care

• Where do the elderly Americans receive their health care?– Community– Hospital– Nursing home

Depression

SickFunctional Impairment

Multiple Chronic Diseases

Not SickFunctionally Intact+ Chronic Diseases

Dementia Diabetes

Specific Diseases

Hospital Nursing Home

End-of-Life

Community

What are the roles of a primary care physician?

OFFICE

PCP

Patient

$

OFFICE

Inside Healthcare PCP Outside Healthcare

Patient/Family

$•Coverage

•Other physicians

•Lab/Tech

•Home Health

•Hospice

•ED

•Pharmacy

•Insurers

$

•Community services

•Support groups

•Living facilities

•Governmental agencies

HOSPITAL OFFICE

$Patient/Family

Physicians

•Hospitalists/Coverage•Other Physicians

PCP

Nursing

Discharge Planning

OFFICE

PCP

NURSING HOME

Patient/Family

Physicians•SNFists•Coverage•Other Physicians

Nursing

Discharge Planning

$

HOSPITAL OFFICE NURSING HOME

PCPPatient/Family Patient/Family

Inside Healthcare Outside Healthcare

Physicians

Nursing

Discharge Planning

Physicians

Nursing

Discharge Planning

$ $

$

Patient/Family

Meeting Population-based Health Needs

• Building systems for caring for patients– Not sick + chronic diseases– Sick, functionally impaired– End of life care

• Managing patient transitions between settings

• Redesigning providers’ roles

Not Sick + Chronic Diseases

• Preventive and Episodic Care – Preventive care is as comprehensive

and inexpensively as possible– Patient trust in the health care system

rather than the individual provider– High caliber, convenient, prompt,

episodic care is available

Not Sick + Chronic Diseases

• Chronic disease care– Team care: who, when, by whom?– Identifiable physician in the team– Disease management strategies– Self-management skills– Shared decision-making

Sick, Functionally Impaired

• Redesigning hospital and nursing home care • Care management-team care

– Disease management and patient management

• Physician intimately involved• Active discussions about prognosis, quality

of life, and preferences for care

End-of Life Care

• Begin process early• Trust between provider and patient• Information sharing

– prognostic– quality of life

• Symptom management• “Polished” end of life care

Managing Patient Transitions Between Settings

• Flow of clinical information between settings• Seamless care shared among different

providers• Ongoing re-evaluation of goals

The Roles of Providers

• Physician’s role will differ based on patient needs– May not be the first or primary contact

• Delegation of responsibilities• Re-examination of scopes of practice

– What’s in a title?– Working to highest level of competency

Framework and principles for successful models

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

Self-Management

Support

Health System

Resources and Policies

Community Organization of Health Care

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Chronic Care Model

Six Guiding Principles for Geriatric Health Care Delivery

1. Care must be personalized to meet each patient’s goals, values, and resources

2. Care should be provided in accordance with best practices

3. It takes a team to provide the best care

Six Guiding Principles for Geriatric Health Care Delivery

4. Care must be coordinated among providers

5. Care must consider the resources and environment of the person

6. Older persons must be included as active partners in their care