IHI.org asked Connie Davis for her thoughts on the website and what she would like to see it accomplish. Here is her reply.

Q: How can IHI.org accelerate improvement in chronic care?

A: Imagine a provider in a fairly rural setting — two to four physician providers in an office, maybe with a nurse practitioner or physician assistant — hearing through the grapevine that better care is possible and can generate much better results for patients. Where can they go? They know about the Institute for Healthcare Improvement (IHI) and they find IHI.org. There they learn about some concrete ideas for changes they could make to help them start to turn around the way they care for patients. As they see how it works, they realize it both improves their practice and increases their own satisfaction. The office then redesigns their whole practice so that they have a really wonderful relationship with patients and the families that they serve, transforming the experience of providing and receiving medical care.

I think helping people in a step fashion — when they are ready, with a tool they can adapt — is a really good resource. A lot of people who are learning ways to change chronic illness care or quality improvement latch onto tools right away because tools promise a quick fix. The real difficulty is the "how": How do I use this tool? How do I change my physician assistant's responsibility so that the patient assessment always gets on the chart? How do I help my receptionist do the depression screening when the people walk in the door? We need to help people see examples of how other people have done it.

I am convinced that we need to share both principles and examples with people. Show them how to test a measure so they can monitor their own progress. Have it packaged in a way that immediately makes sense. Capitalize on the tools that have been developed by other providers.

 

Q: What is the Chronic Care Model and how can organizations use it?

A: The Chronic Care Model basically says that the good outcomes in health care — things like better clinical control, better self-confidence and quality of life for patients, lower costs in health care — are the result of productive interaction between provider teams who are prepared and proactive and patients, families, or care-givers who are active and ready to take on their part of the care dyad.

To make those productive interactions happen, there are certain things to pay attention to in the office practice. We put these into four categories of things you do to support patients, while recognizing that in a well-designed system they all interact with each other:

The first category is self-management. It's about empowering patients: using motivational interviewing skills and building assessment, tailoring, problem solving and goal setting into everyday care.

The second category is delivery system design. Who is on the care team? What kind of interaction do they have with the patient — delivering the effective services that we know work, like case management services, group visits, planned visits, and follow-up. How do team members interact? How to telephone? How to e-mail?

The third category is decision support. That means that the providers know what the effective care is. They have a guideline they are following that is embedded in practice so it is hard to ignore it. Patients are also aware of the guidelines, and understand what their own goals are. It includes making sure that the members of the practice team have a way to get their skills updated regularly through effective methods, and that they have ways to interact with specialists when they need to. Most of our work is with primary care doctors so we kind of think in that world. Primary care doctors need specialists' support. They need to know when it is appropriate to refer, when people should be coming back. They need to have ways to get their questions answered right away.

The fourth category is clinical information systems. This is a way of capturing the information so that it is there in front of the patient and provider when it is needed. A lot of people think of this as a registry. A registry is just a way of collecting information so that you have it for the entire population. Right now we are seeing the transition where there are electronic medical records that are beginning to be able to do that, but we really need to not lose that population focus. The registry or the clinical information system is also where the providers get their feedback on how they are doing both for individual patients or groups of patients or subgroups of patients.

A way to make this concrete for providers is, what if you found out yesterday that a very popular diabetes medication is now found to cause liver damage? How would you find all the patients you prescribed that medication to and call them in to test their liver function? That is the kind of information system we need because it helps us subgroup patients in useful ways. It gives us a feedback loop, helps us with measurement, and also helps the patient have the information in front of them that they need to self-manage. The care plan also comes out of that information system.

We know that office practice exists within an organization of health care itself so there are some important things to foster at the higher level of the organization. What are the senior leader’s goals around health care quality? What does the business plan say to make the goals actionable? Does it say we value taking care of people with chronic illnesses? What is the method(s) used for quality improvement? What is the incentive system? Are we rewarding providers for doing a really good job with clinical care?

And finally, the whole system — the patient, provider, and the health care system — exists within the community. There are resources and policies that will also influence the kind of interaction that patients can have. Is there an exercise program? Are there places to walk? Are there Meals on Wheels? Are there visiting nurses? Medication programs? Lots of things like that can assist patients primarily and also providers to provide care.

 

Q: What are you curious about achieving on the website?

A: Some of the things I think we are learning about are decisions in the developing world. We have been fortunate enough to work a little bit with the World Health Organization and they have taken the Chronic Care Model and adapted it to the developing world. Outside the US, the community and the policies at the national level rise in importance when they look at the Care Model. I think we can learn a lot about the principles and how they are adapted in different settings. We already know a little about countries where there is the single-payor program like Canada or Sweden. There are some efficiencies that help a lot. I think it will help us learn if we have a framework that is comprehensive.