The Chronic Disease Model The Chronic Disease Model – Planned Visits– Planned Visits

It takes more than a “smart” It takes more than a “smart” doctor….doctor….

The ProblemThe Problem

• ““Too often, caring for chronic Too often, caring for chronic illness features an uninformed illness features an uninformed passive patient, interacting with passive patient, interacting with an unprepared practice team, an unprepared practice team, resulting in frustrating, resulting in frustrating, inadequate encounters.”inadequate encounters.”

The InterventionThe Intervention

• The Planned Visit - a component of the Chronic Care Model The Planned Visit - a component of the Chronic Care Model developed by Ed Wagner and colleagues at the MacColl developed by Ed Wagner and colleagues at the MacColl Institute for Healthcare Innovation at Group Health Institute for Healthcare Innovation at Group Health Cooperative in Seattle. The purpose of the visit is to ensure Cooperative in Seattle. The purpose of the visit is to ensure that the clinical team reviews the care for each patient with a that the clinical team reviews the care for each patient with a chronic illness and is proactive in providing the patient with chronic illness and is proactive in providing the patient with all the elements of evidence-based care for his or her all the elements of evidence-based care for his or her condition, including training in self-management. condition, including training in self-management.

• These visits are pre-scheduled one-on-one visits, 20 to 40 These visits are pre-scheduled one-on-one visits, 20 to 40 minutes in length. During the visit, the clinical team and the minutes in length. During the visit, the clinical team and the patient review the patient’s progress and work on clinical and patient review the patient’s progress and work on clinical and self-management topics. A typical visit might cover some self-management topics. A typical visit might cover some challenging aspect of self-management, such as medication challenging aspect of self-management, such as medication adherence. Other health professionals, such as pharmacists, adherence. Other health professionals, such as pharmacists, nurses, nutritionists, etc., may also play a role by identifying nurses, nutritionists, etc., may also play a role by identifying appropriate patients, preparing for the visit, or participating appropriate patients, preparing for the visit, or participating with the primary care physician in the visit. with the primary care physician in the visit.

Planned VisitsPlanned Visits

• This approach gives clinicians and This approach gives clinicians and patients the opportunity to review and patients the opportunity to review and strengthen the patient’s self-strengthen the patient’s self-management of his or her chronic illnessmanagement of his or her chronic illness

• Planned visits can fill the gap left by Planned visits can fill the gap left by acute care visits which, because of their acute care visits which, because of their focus on immediate symptoms, focus on immediate symptoms, frequently allow little time for this kind of frequently allow little time for this kind of interaction. interaction.

Potential Benefits of Planned Potential Benefits of Planned VisitsVisits

• Improved clinical care (reduced A1c, BP Improved clinical care (reduced A1c, BP control, etc)control, etc)

• Reduced symptomsReduced symptoms• Improved overall healthImproved overall health• Fewer acute care visits, reduced costs, Fewer acute care visits, reduced costs,

and greater patient satisfactionand greater patient satisfaction• Increased patients’ sense of control Increased patients’ sense of control

over their health by providing them over their health by providing them with ways to manage their own illnesswith ways to manage their own illness

Improving CommunicationImproving Communication

• Better communication is a 2-way Better communication is a 2-way streetstreet

• Health Care Providers need to Health Care Providers need to communicate in effective and communicate in effective and understandable waysunderstandable ways

• Patients need to be given the tools to Patients need to be given the tools to communicate effectively as wellcommunicate effectively as well

The Communication The Communication ProblemProblem• Many if not most patients are just beginning to become Many if not most patients are just beginning to become

comfortable with relationships with clinicians that are based on comfortable with relationships with clinicians that are based on a partnership model rather than the traditional paternalistic a partnership model rather than the traditional paternalistic model. This shift is especially difficult for older patients and model. This shift is especially difficult for older patients and people who do not speak English or who come from cultures people who do not speak English or who come from cultures where this kind of a relationship with a doctor is unheard of. where this kind of a relationship with a doctor is unheard of.

• But even those who embrace the idea of working But even those who embrace the idea of working collaboratively with physicians may lack important collaboratively with physicians may lack important communication skills, which can inadvertently undermine their communication skills, which can inadvertently undermine their interactions with the health care system.interactions with the health care system.

• Beginning in childhood, people are socialized to restrain Beginning in childhood, people are socialized to restrain themselves with doctors, answering only what they have been themselves with doctors, answering only what they have been asked. While this attitude is changing, it is still a big step for asked. While this attitude is changing, it is still a big step for people to accept that their agenda is as important as the people to accept that their agenda is as important as the doctor’s, and an even bigger one for them to learn how to doctor’s, and an even bigger one for them to learn how to satisfy that agenda while still respecting the clinician’s satisfy that agenda while still respecting the clinician’s constraints. constraints.

Communication - The Communication - The InterventionIntervention

• Patients who can communicate effectively Patients who can communicate effectively with their clinicians tend to be more satisfied with their clinicians tend to be more satisfied with their care and less likely to sue in case with their care and less likely to sue in case of an error. Their clinicians are likely to be of an error. Their clinicians are likely to be more satisfied with their caregiving more satisfied with their caregiving experience as well. experience as well.

• There are several ways to implement this There are several ways to implement this strategy, including the tactics listed below:strategy, including the tactics listed below:– Record Sharing Record Sharing – Patient Question Lists (a.k.a. Doc Talk Cards) Patient Question Lists (a.k.a. Doc Talk Cards) – Coached Care Coached Care

Communication ToolsCommunication Tools

• Record Sharing -Record sharing involves Record Sharing -Record sharing involves using the patient’s medical record as a using the patient’s medical record as a way to facilitate information sharing and way to facilitate information sharing and generate discussion in the context of generate discussion in the context of primary care. It typically consists of primary care. It typically consists of giving patients a copy of their giving patients a copy of their physicians’ progress notes (on paper or physicians’ progress notes (on paper or electronically) together with a glossary electronically) together with a glossary of terms. This is being piloted in various of terms. This is being piloted in various health systemshealth systems

Communication Communication InterventionsInterventions• Patient Question Lists (a.k.a. Doc Talk Cards) Patient Question Lists (a.k.a. Doc Talk Cards)

Encourage patients to write down questions Encourage patients to write down questions they wish to ask their doctor and bring the list they wish to ask their doctor and bring the list to their visit; these lists are sometimes referred to their visit; these lists are sometimes referred to as “Doc Talk” cards. Typically, patients are to as “Doc Talk” cards. Typically, patients are asked to generate two to five questions about asked to generate two to five questions about their medical problems or their reason for the their medical problems or their reason for the visit that they would like their physician to visit that they would like their physician to answer during the office visit. The cards are answer during the office visit. The cards are often designed to prompt patients for questions often designed to prompt patients for questions by listing topic areas such as symptoms and by listing topic areas such as symptoms and medications. medications.

Improved communication – Improved communication – DocDoc TalkTalk

• One tactic is to provide a form on the One tactic is to provide a form on the internet that patients can print out prior to internet that patients can print out prior to their visit. Some health plans, for example, their visit. Some health plans, for example, offer members a form that suggests they offer members a form that suggests they write out answers to the following two write out answers to the following two questions and bring their response to the questions and bring their response to the visit:visit:

• What do I want to What do I want to telltell my doctor today? my doctor today?

• What do I want to What do I want to askask my doctor today? my doctor today?

Improved Communication – Improved Communication – Coached Care ModelCoached Care Model• ““Coached Care” programs are designed to prepare patients to be more effective Coached Care” programs are designed to prepare patients to be more effective

participants in their care by teaching them how to ask the right questions, how to participants in their care by teaching them how to ask the right questions, how to interrupt, and how to get their needs met in the encounter. Coaching sessions may interrupt, and how to get their needs met in the encounter. Coaching sessions may also address common misconceptions regarding a condition. Its goals include helping also address common misconceptions regarding a condition. Its goals include helping people become more assertive health care consumers, improving the quality of people become more assertive health care consumers, improving the quality of interpersonal care, and increasing patient involvement in treatment decisions. interpersonal care, and increasing patient involvement in treatment decisions.

• The design of Coached Care programs varies from the inexpensive, where patients The design of Coached Care programs varies from the inexpensive, where patients receive brochures prior to their visits that contain a list of common questions and receive brochures prior to their visits that contain a list of common questions and other prompts, to more expensive programs involving individual coaching sessions other prompts, to more expensive programs involving individual coaching sessions between patients and designated clinic staff. For example, just prior to a doctor visit, between patients and designated clinic staff. For example, just prior to a doctor visit, a nurse may interview the patient, review the chart together, and generate a list of a nurse may interview the patient, review the chart together, and generate a list of questions the patient has for the doctor. These more involved coaching programs questions the patient has for the doctor. These more involved coaching programs require larger resources for staff training in Coached Care techniques in addition to require larger resources for staff training in Coached Care techniques in addition to financial coverage of staff time. While coaching sessions are usually performed in an financial coverage of staff time. While coaching sessions are usually performed in an office setting, they may also take place through e-mail or over the phone. office setting, they may also take place through e-mail or over the phone.

• Coached care programs have been shown to improve both physiologic and functional Coached care programs have been shown to improve both physiologic and functional outcomes.  A 1995 literature review of 21 studies found a definite correlation outcomes.  A 1995 literature review of 21 studies found a definite correlation between effective physician-patient communication and improved patient health between effective physician-patient communication and improved patient health outcomes In addition, anecdotal evidence suggests that Coached Care programs outcomes In addition, anecdotal evidence suggests that Coached Care programs enhance physician-patient enhance physician-patient communication communication withoutwithout requiring an increase in visit requiring an increase in visit lengthlength

Steps to Conducting Effective Steps to Conducting Effective Planned VisitsPlanned Visits

• Choose a patient population to focus on (e.g., Choose a patient population to focus on (e.g., diabetics, asthmatics, heart disease patients). diabetics, asthmatics, heart disease patients).

• Generate a list of patients at particular risk Generate a list of patients at particular risk within the group. Patients at risk could include: within the group. Patients at risk could include: – Those who are not adhering to their medications Those who are not adhering to their medications – Those with clinical evidence of poor disease control Those with clinical evidence of poor disease control – Those who have not received important medications Those who have not received important medications

or other services indicated for their conditionor other services indicated for their condition

Steps to Effective Planned Steps to Effective Planned VisitsVisits• Call patients and explain the need for a visit:Call patients and explain the need for a visit:

– Script the phone call as follows:Script the phone call as follows:– Hello Mrs_________Hello Mrs_________

This is Dr._____from Jacobi Medical Center. I am very interested in making sure that all my patients with This is Dr._____from Jacobi Medical Center. I am very interested in making sure that all my patients with Diabetes Mellitus are receiving the best care possible. I would like you to come to see me for a Diabetes Mellitus are receiving the best care possible. I would like you to come to see me for a special appointment to discuss your Diabetes. If you have other health concerns, we may need to special appointment to discuss your Diabetes. If you have other health concerns, we may need to address those at a future visit. By focusing just on your diabetes both you and I can better manage address those at a future visit. By focusing just on your diabetes both you and I can better manage your health.your health.

Can we set up a time that is convenient for you? When you come please bring all your current Can we set up a time that is convenient for you? When you come please bring all your current medications (and anything else important to the condition – log book etc) medications (and anything else important to the condition – log book etc)

Also, please think of 2-3 things you would like to ask me or tell me related to your diabetes. Write them Also, please think of 2-3 things you would like to ask me or tell me related to your diabetes. Write them down so that we are sure to talk about them at your visit. Thank you. We will call you a day before down so that we are sure to talk about them at your visit. Thank you. We will call you a day before the visit to make sure that you are still able to come.the visit to make sure that you are still able to come.

• Schedule the visit and instruct the patient to bring all medications, glucose log books, meter, BP log Schedule the visit and instruct the patient to bring all medications, glucose log books, meter, BP log etc.etc.

• To identify the patient’s concerns ask the patient to prepare “Doc Talk” cardsTo identify the patient’s concerns ask the patient to prepare “Doc Talk” cards• Prepare for the visit (e.g.review the patients record and decide, in advance what to focus on in the Prepare for the visit (e.g.review the patients record and decide, in advance what to focus on in the

visit)visit)

Call the Patient to Schedule a Call the Patient to Schedule a Visit:Visit:• Hello Mrs_________Hello Mrs_________This is Dr._____from Jacobi Medical Center. I am very interested in This is Dr._____from Jacobi Medical Center. I am very interested in

making sure that all my patients with Diabetes Mellitus are making sure that all my patients with Diabetes Mellitus are receiving the best care possible. I would like you to come to see receiving the best care possible. I would like you to come to see me for a special appointment to discuss your Diabetes. If you me for a special appointment to discuss your Diabetes. If you have other health concerns, we may need to address those at a have other health concerns, we may need to address those at a future visit. By focusing just on your diabetes both you and I can future visit. By focusing just on your diabetes both you and I can better manage your health.better manage your health.

Can we set up a time that is convenient for you? When you come Can we set up a time that is convenient for you? When you come please bring all your current medications (and anything else please bring all your current medications (and anything else important to the condition – log book etc) important to the condition – log book etc)

Also, please think of 2-3 things you would like to ask me or tell me Also, please think of 2-3 things you would like to ask me or tell me related to your diabetes. Write them down so that we are sure to related to your diabetes. Write them down so that we are sure to talk about them at your visit. Thank you. We will call you a day talk about them at your visit. Thank you. We will call you a day before the visit to make sure that you are still able to come.before the visit to make sure that you are still able to come.

Effective Planned Visits – Effective Planned Visits – during the visitduring the visit

• Restate the reason for this visit - frame the Restate the reason for this visit - frame the visitvisit

• Review all pertinent information, meds, logs Review all pertinent information, meds, logs etcetc

• Review Talk-Doc questions or concerns Review Talk-Doc questions or concerns prepared in advance by the patientprepared in advance by the patient

• Set an Action Plan – sign and copy agreementSet an Action Plan – sign and copy agreement

• Ask the patient to review the plan - decide on Ask the patient to review the plan - decide on the follow up timeframethe follow up timeframe

Self- Management SupportSelf- Management Support

• Supporting patients in managing their Supporting patients in managing their own chronic conditions requires more own chronic conditions requires more than education or information on the than education or information on the clinical – they need skills and clinical – they need skills and confidenceconfidence– In learning to manage the illnessIn learning to manage the illness– In learning to carry on normal roles and In learning to carry on normal roles and

activitiesactivities– In learning to manage the emotional In learning to manage the emotional

impact of the illnessimpact of the illness

Building Self-Management Building Self-Management Support Into the Planned Care Support Into the Planned Care Visit: Making Visit: Making a Specific a Specific PlanPlan• Goal Setting and Action Planning – Goal Setting and Action Planning –

technique for helping patients in working technique for helping patients in working towards healthier behaviorstowards healthier behaviors– This takes place after assessment and This takes place after assessment and

engagement of the pt in decision making engagement of the pt in decision making regarding medical managementregarding medical management

– Initiate the discussion: “Is there anything you Initiate the discussion: “Is there anything you would like to do this week to improve your would like to do this week to improve your health? “ This allows the pt to choose which health? “ This allows the pt to choose which behavior they are motivated to change and behavior they are motivated to change and forms the basis for setting a behavior-change forms the basis for setting a behavior-change goalgoal

Goal Setting and Action Goal Setting and Action PlanningPlanning

• After the patient has agreed on a general After the patient has agreed on a general goal (eg- to lose 10 pounds) then -goal (eg- to lose 10 pounds) then -– Negotiate a specific action plan to assist in goal Negotiate a specific action plan to assist in goal

attainment (eg -substitute water for soda)attainment (eg -substitute water for soda)• Goals are more general – Action Plans are highly Goals are more general – Action Plans are highly

specificspecific

• Patients should have a high level of confidence in their Patients should have a high level of confidence in their ability to carry out the plan – if not adjust the planability to carry out the plan – if not adjust the plan

• Success is directly related to self-efficacy (confidence Success is directly related to self-efficacy (confidence that one can make positive life changes - success that one can make positive life changes - success builds on itself and failure - the oppositebuilds on itself and failure - the opposite

Action PlansAction Plans

After the Visit – “it takes more After the Visit – “it takes more than than a smart doctor”a smart doctor”

• Copy of the action plan to the patient and Copy of the action plan to the patient and to you (or to the EMR when feasible)to you (or to the EMR when feasible)

• Phone call will be made to the patient to Phone call will be made to the patient to follow up on goals made –usually within 1 follow up on goals made –usually within 1 weekweek

• Action plan discussed at next appt as well Action plan discussed at next appt as well – encouragement, positive feedback and – encouragement, positive feedback and problem solving to help move towards problem solving to help move towards chosen goalschosen goals

Follow Up and Problem Follow Up and Problem SolvingSolving• Long term behavior change will require moreLong term behavior change will require more• Studies have shown that regular and sustained Studies have shown that regular and sustained

follow-up is a necessary component – follow-up is a necessary component – who will who will do this ? – It depends!do this ? – It depends!

• Telephone, face to face, email – individually or Telephone, face to face, email – individually or in groupsin groups

• Follow-up will include problem solving – Follow-up will include problem solving – barriers to success in carrying out the action barriers to success in carrying out the action planplan

• These are” lessons learned” – never“failures” These are” lessons learned” – never“failures” and the discussion should be framed in this and the discussion should be framed in this wayway

Practicum:Practicum:

• Choose 3 patients - either from your registry or pts who you have Choose 3 patients - either from your registry or pts who you have seen in recent months with DMseen in recent months with DM

• Planned Visit ProtocolPlanned Visit Protocol– Call the patient – agree on appt – only 3 pts for the session – 40 Call the patient – agree on appt – only 3 pts for the session – 40

mins/ptmins/pt– Have the pt prepare for the visit – bring all meds etc etc, prepare Have the pt prepare for the visit – bring all meds etc etc, prepare

questions for youquestions for you– Review in advance – have a clinical plan in mind, decide what the Review in advance – have a clinical plan in mind, decide what the

patient needs to have done – write this down so you are prepared for patient needs to have done – write this down so you are prepared for each patienteach patient

– Planned visit – focus only on the DM, go through all the clinical info with Planned visit – focus only on the DM, go through all the clinical info with the pt – shared decision making regarding a treatment planthe pt – shared decision making regarding a treatment plan

– Answer Talk-Doc questions/concernsAnswer Talk-Doc questions/concerns– Goal Setting and Action Plan for behavioral change if the patient is Goal Setting and Action Plan for behavioral change if the patient is

readyready– Have patient review the clinical plan and action planHave patient review the clinical plan and action plan– Decide on follow up – ask permission to call in 1 week and set up a Decide on follow up – ask permission to call in 1 week and set up a

future appt soon – no more than 4 weeksfuture appt soon – no more than 4 weeks