Implementing the Planned Care Model
For nearly a century, U.S. physicians have used the same model in their practice of medicine: Patients called the doctor’s office for an appointment and took the first available slot. Sometimes that appointment was days or weeks into the future. Once in the office, the doctor managed a patient’s care, telling her what medicine to take or how to change his lifestyle. Then the patient left the office and didn’t come back again unless the doctor wanted them to make a follow-up appointment or they were sick or injured.
After World War II, Japan was struggling to rebuild its shattered industrial base when the late W. Edwards Deming, an American statistician and industrial engineer, was sent to work in the country. Dr. Deming taught Japanese companies about front-line problem solving and Total Quality Management. Toyota and other Japanese companies adopted Dr. Deming’s ideas and became the envy of the manufacturing world. Many other industries eventually revised their operating standards and adopted Dr. Deming’s principles. But not health care.
Then, in 1991, a forward-thinking pediatrician in Boston decided that it was time for health care to re-examine its methods of service delivery. He founded the Institute for Healthcare Improvement (IHI) with the idea of doing for medicine what Dr. Deming had done for manufacturing (www.ihi.org). In 1998, the Bureau of Primary Health Care, a part of the federal Department of Health and Human Services, contacted Clinica to see if some of our staff would be in interested in learning about IHI’s ideas. Clinica was one of only five community health centers in the country to be invited to IHI’s training. Our organization was in a period of rapid growth. Huge numbers of people who could no longer get medical care at Denver Health and Hospitals were swarming to our clinics. With so many new patients, our staff was overwhelmed. We watched as patient outcomes slid in the wrong directions. Diabetics were not controlling their bloodsugar levels; asthmatics were ending up in emergency rooms more often; prenatal patients were having smaller babies. With such outcomes on their minds, our physicians were excited – but skeptical – about a new approach to primary care.
Our staff came back from the IHI seminar touting something called the Chronic Care Model (also known as the Planned Care model). This new approach to health care had six components:
- Applying changes across an organization and making sure organization leaders are visible, dedicated and accessible.
- Redesigning the delivery of care so that patients receive regular, proactive, planned visits.
- Assuring that clinicians have ready access to the most current, evidence-based guidelines for care and receive continuing education.
- Utilizing powerful technology so that clinicians have access to lists of their patients who have specific diseases (e.g., a list of diabetic patients, a list of asthmatics, etc.). These lists, or registries, provide clinicians with information and assure that patients receive the care they need.
- Encouraging patients to become an active part of their health care. As part of their appointments, clinicians have patients set personal health goals (walking, losing weight, etc.) and learn to monitor their own conditions.
- Helping patients find community resources to meet non-medical needs.
After piloting a small project of our own, Clinica directors decided that our organization and patients would benefit from incorporating the Chronic Care Model into all of our clinics. Since making that decision six years ago, we have:
- Re-organized our facilities into “mini-clinics” or “pods” so that a consistent team of providers (three clinicians, nurses and medical assistants, a receptionist, a medical records technician, a financial screener, a case manager, a social worker, etc.) works together to care for the same panel of patients. Our buildings are architecturally designed to accommodate this style of care delivery. (For more about this, see the “Providers” page of this web site.)
- Added a case manager or social worker to each pod to provide community resource help.
- Changed our work flow so that once a patient is weighed, she goes into an exam room and all services come to her. This reduces the traffic and noise in our hallways.
- Changed our work habits so that we “do today’s work today.” For years, Clinica had scheduling practices similar to those found in most private practice offices. Patients would call wanting an appointment. If they thought their need was urgent, a triage nurse would talk with the patient and possibly schedule an appointment. If it wasn’t an urgent matter (e.g., a routine physical), the patient would be given the first available appointment, which might be a 3-8 week wait. By time the appointment arrived, the patient might have other plans, not have access to transportation, not want the appointment or might have completely forgotten. We have changed our scheduling policies so that 70% of a day’s appointments are available that day. Most people can be seen within hours, decreasing the likelihood that they will go to an emergency room for primary care and reducing our “no show” rate from 36% to 8%.
- Encouraged patient to make self-management goals and have supported patients so that they become our partners in their medical care.
- Encouraged our clinicians to practice evidence-based medicine and have made updated clinical guidelines available to all providers on a central computer network. (For more on how Clinica implemented the use of evidence-based medicine, see the “Electronic Health Record and Evidence-based Medicine” page of this web site.)
- Begun utilizing group medical visits, where a number of individuals with the same condition (such as diabetes) or the same health need (school physicals) can see a physician as a group. This been an effective means of delivering education and non-confidential health care to 20 patients simultaneously and is also been an excellent opportunity for patients to provide support and encouragement to each other. (For more on this subject, see the “Group Visits” page of this web site.)
- Examined our entire patient census and found the most common primary care medical needs that have the worst potential outcomes and highest expense if left untreated. For our patients, these are:
- prenatal care (specifically smoking cessation)
- and diabetes.
- We decided to focus most of our efforts on these areas. In these five areas of care, our clinicians have developed treatment guidelines and established health goals based on the most current medical evidence available. We have built databases or “registries” to collect information in these five areas to assure that patients receive the care they need in a timely fashion. These registries are the linchpins of our system. They help clinicians determine what treatments work and which don’t. They keep patients from falling through the cracks, and they provide invaluable information. For example, the registries were the key to helping our providers drop the average HbA1c level of our diabetic patients from 10.8 to 8.1. That 2.7-point drop means that most of our patients are no longer high-risk candidates for the kidney disease, amputations, blindness or heart disease associated with extremely high blood sugar levels.
The success of the Chronic Care Model at Clinica has been so tremendous that our organization was cited in an article published in the October 2002 issue of the Journal of the American Medical Association (link here) as an example of how to provide high-quality care to people with chronic diseases. The Institute for Healthcare Improvement and the National Coalition on Health Care have also cited Clinica in publications and on their web site as a national model for improving chronic disease management.
Our organization has grown xxx% in the past 10 years.
When the first waves of new patients began crashing on our phone receptionists, we simply tried to get patients in to see a clinician – any clinician – as quickly as possible. Despite getting patients in for appointments, we were seeing a strong downward trend in their healthcare outcomes. HbA1c levels were rising, asthma attacks needing emergency treatment were increasing, blood pressures were on the increase. That was not true, however, for the patients who really liked a particular clinician and insisted on seeing that person at each visit. Those insistent patients taught us that continuity of care and strong patient-provider relationships make a tremendous difference in a patient’s health. Now, one of the first things we do with new patients is make sure they have a primary care provider. They can choose their provider or change providers at a later date, but they have a PCP. Next, we subdivided each of our clinics into “mini clinics” or “pods.” Each pod consists of three FTE clinicians, a nurse manager, three FTE medical assistants, a case manager or social worker and two office technicians. Instead of specializing in an age group (such as pediatrics) or a disease process (such as oncologists), our teams specialize in a group of about 3,200 patients. All of the clinicians know each other’s patients so they can cover for each other. Clinicians work with a set medical assistant so that patients know support staff well. By knowing their patients, clinicians don’t have to spend as much time reviewing a chart before they begin an appointment. Patients have greater trust in their clinicians and are more frank with them.
Wagner EH. “Chronic Disease Management: What Will It Take To Improve Care For Chronic Illness?” Effective Clinical Practice. 1998;1:2-4.