The Chronic Care Model--A Quality Innovation

The background of this health system model & how one system, Care SouthCarolina, has been financially rewarded since implementing it

by Marlene Piturro, PhD, MBA

Changing the way physicians and others work with chronically ill patients to provide more and better services while increasing revenues is the goal of proponents of the chronic care model (CCM).

Ann Lewis, executive director of Care SouthCarolina, Inc., embraced CCM after making "every mistake possible with it. But now we're married to it. It moved from a pilot project to the way we do business," she said.

So what made this 25-year Care SouthCarolina veteran put herself and her organization through the gut-wrenching change to become a CCM? Part of it was hope for better outcomes--like the 20% increase in their providers' productivity and the organization's 72% six-month follow-up rate for patients in treatment for depression. (Compare this with the national average of 25%.)

The other part was the amazing switch from struggling to recruit physicians to work in a poor, rural area to "visiting the University of South Carolina medical school and having newly-minted physicians' eyes light up when we tell them about our model of care," said Lewis.

Simply put, CCM revamps the traditional medical office practice design, which depends on private office visits, physician memory, written medical records, and inadequate patient involvement. With a clear definition of optimal care, a roadmap for changing the system, and an improvement strategy phased in as daily operations continue, many office practices and health systems are going from struggling to thriving enterprises via CCM.

Below, the background of this system model and the story of how Care SouthCarolina took the CCM plunge.

Success by Numbers

Supported by grants from the Robert Wood Johnson Foundation/Improving Chronic Illness Care (ICIC), the Institute for Healthcare Improvement (IHI), and approximately 100 provider organizations in the United States and Canada, the CCM quality improvement initiative is based on a business model of health-care management from the vantage point of a primary care practice. CCM enables physicians and facilities to maximize revenue by reevaluating how they use their practices' resources. (See "The ICIC Process," below.)

Care SouthCarolina, a private non-profit community health center serving five rural counties with a large population of poor elderly in South Carolina's Pee Dee region, experienced "stunning, breakthrough changes since we became involved in IHI in 1999," explained Lewis. "We went from deficit spending then to a 7% positive cash flow now; our doctors spend an average of 12.5 versus 8.2 minutes with each patient; our behavioral health costs are two-thirds less than similar programs; and the HbA1c levels of our diabetic patients are down from 13 to 8.1.

"Just taking the last figure--every one point decrease in HbA1c results in a decrease in mortality of 18%," she enthused.

Impressive results. Care SouthCarolina has also experienced heightened productivity: An annual average of 6,572 patient encounters per provider, versus 4,100 nationally. Care SouthCarolina posted other notable gains in 2002 (the most recent year for which data are available). (See "Care SouthCarolina 2002 Statistics," right.)

Roger Chaufournier, president and CEO of Rochester, N.Y.-based Patient Infosystems and an IHI member, attributed Care SouthCarolina's success with the commitment made by Lewis and her colleagues to pursue their view of what an idealized health system could look like based on its human resources. He cited changing their care model from a traditional system to the CCM, particularly their planned visits and care manager teams, as keys to the change process. Chaufournier helped Lewis implement the CCM and regularly visits Care SouthCarolina to study its progress.

The Medical Director's Vantage Point

Steven Smith, MD, Care SouthCarolina's medical director, uses the health plan's redesign to spend more time on the nursing-home practice he enjoys. Dr. Smith splits his time between caring for the frail elderly at his office and in Care SouthCarolina nursing facilities (NFs); he spends weekday afternoons in three rural NFs that house 400 total patients. Because he practices in both office and NF settings, he can easily observe the effects of the CCM.

"The improvements in the office setting are dramatic and dynamic, particularly in the patient self-management components. To keep patients motivated between office visits and then to see improvements in health outcomes is very gratifying. We see less of that excitement and motivation in the nursing home" he said. "Because the residents live there and are usually quite ill and/or cognitively impaired, we don't expect to improve outcomes and prolong life substantially; however, we can make the residents a lot more comfortable."

Also missing from the NFs but present in the clinics is the information technology (IT) system that allows physicians to track their own performance on health outcomes for chronic conditions.

A major change under the revamped Care SouthCarolina chronic care system: Behavioral health-care teams work on site in the NFs to detect and treat depression and other conditions that require psychoactive drugs. Dr. Smith has also implemented evidence-based medicine, including the American Medical Directors Association guidelines for CHF and wound care, increased emphasis on pain management, and more systematic tracking of required periodic patient tests.

The important ways in which the NF CCM differs from the outpatient setting: The outpatient setting is not part of the sophisticated IT system and deemphasizes patient self-management.

"The good thing about nursing home care is that the barriers to care that exist in outpatient settings, such as keeping appointments, disappear," added Dr. Smith.

Dr. Smith would like to extend Care SouthCarolina's sophisticated clinical information system (CIS), the electronic database that provides clinicians with a list of each of their patients with a chronic disease and tracks their health outcomes from the clinics to the NFs.

"We don't have it yet, although three months ago the data tools were deployed to every outpatient site," he explained. "I find that the CIS motivates the physicians to improve their performance and outcomes. We're always asking ourselves if we're doing as good a job as we can, and the CIS proves it when we are."

Financial Boons

One obvious obstacle to a wholehearted embrace of the CCM is the current reimbursement system. Lewis reported that the Medicare and Medicaid payment structures pose a serious challenge to administrators trying for financial viability in a tough reimbursement climate.

"CMS is beginning to recognize this dilemma by offering demonstration grants to make the business case for changing the reimbursement systems, aligning outcomes with how it pays for chronic illnesses," noted D r. Smith. "[There are] huge disincentives to our model with fee-for-service Medicare. Yes, CMS will save a ton of money, but the NFs and physicians can lose if the model isn't thoroughly thought through." (For more information or to access analytic tools for practice model redesign, visit www.ptisys.com or contact rchaufournier@ptisys.com.)

While making the CCM work with fee-for-service reimbursement is challenging, a capitated health plan that assumes risk and delivers quality care cost effectively can do well. Brian Fillipo, MD, associate chief medical officer of Geisinger Health Systems, Danville, Pa., a health plan that services a largely Medicare-eligible population of more than 300,000 members in rural Pennsylvania, explained that CIS is the system's foundation.

"We started building our electronic medical record in 1996, and it was fully implemented in 2002," he explained. "Our 250 primary care physicians and 250 plus specialists get monthly registry reports for all patients identified with chronic diseases such as diabetes, hypertension, CHF, and atrial fibrillation; see popup windows if tests or other treatments are overdue; view a preventive medicine box to alert them [to] what tests should be given at the next planned visit; and a host of guidelines and other clinical support tools."

To update guidelines for a particular chronic condition, a small team of physicians, led by a clinical champion, reviews new evidence about treatment outcomes, incorporating changes as agreed upon by consensus.

Financially, Geisinger Health Systems is succeeding. Hoover's Online reported 2002 revenue growth of 9.1% with no increase in employment over 2001. While Geisinger doesn't serve long-term care facilities, Dr. Fillipo said "the CCM has a great deal to offer them in managing the diseases of old age" and called the current reimbursement process "a broken system that must be redesigned. We must have and we will have a reimbursement system that is based on outcomes."

The Road Ahead

Despite the successful experiments with the CCM achieved by Care SouthCarolina and IHI's other members, there's still a long way to go. According to Lawrence Casalino, MD, PhD, of the University of Chicago, Department of Health Studies, millions of patients with chronic diseases are not receiving the care management processes that have been recommended to improve their conditions.

In a study of physician groups with 20 or more physicians, only 32% used 16 recommended care processes, including disease registries, nurse care managers, patient self-management, and physician feedback on quality of care (Casalino L, et al. External incentives, information technology and organized processes to improve quality: results of the first national survey of physician organizations. JAMA;289:434-441).

That will change if Lewis and others committed to the CCM continue to succeed. "We've seen amazing changes, but the process requires constant testing, coaching, and adaptation," she concluded. "When you see the improvements in outcomes that we have, it makes all the effort worth it."

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