Chronic Care Challenges: People, Places, and Principles David B. Reuben, MD Archstone Foundation Chair and Professor David 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
Hospital Nursing Home Not Sick Functionally Intact + Chronic Diseases Sick Functional Impairment Multiple Chronic Diseases End-of-Life Community Specific Diseases Depression Dementia Diabetes
What are the roles of a primary care physician?
OFFICE PCP $ Patient
OFFICE Inside Healthcare PCP Outside Healthcare $ Coverage Other physicians Lab/Tech Home Health Hospice ED Pharmacy Insurers $ Patient/Family Community services Support groups Living facilities Governmental agencies
HOSPITAL Patient/Family $ OFFICE PCP Physicians Hospitalists/Coverage Other Physicians Nursing Discharge Planning
OFFICE PCP $ NURSING HOME Patient/Family Physicians SNFists Coverage Other Physicians Nursing Discharge Planning
HOSPITAL OFFICE NURSING HOME Patient/Family $ $ PCP Inside Healthcare Outside Healthcare Patient/Family Physicians $ Physicians Nursing Patient/Family Nursing Discharge Planning Discharge Planning
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
Chronic Care Model Community Resources and Policies Health System Organization of Health Care Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes
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