Planned Care Model (Chronic Care Model or Care Model)
“The model of care for chronic illness is a population-based model that relies on knowing which patients have the illness, assuring that they receive evidence-based care, and actively aiding them to participate in their own care.”
- Dr. Ed Wagner- MacColl Institute for Healthcare Innovation, Group Health Cooperative
Much of the work in primary care services provided in any healthcare system could be characterized as reactive and chaotic, rather than proactive and organized. The following scenario is so common, it happens all to often in the primary services provided to many patients:
A patient with uncontrolled hypertension scheduled for a 15-minute follow-up visit complains of an upper respiratory infection, so you treat the URI and then quickly adjust the patient's hypertension meds and exhort the patient one more time to please follow through and get that colonoscopy. Blearily dictating your note later that night after the kids are in bed, you realize that you haven't followed up on the patient's iron deficiency anemia in ages, and you wonder if the lack of refills on thyroxine is a charting error or if the patient has just stopped taking the medication.
- Excerpt from “Escaping the Tyranny of the Urgent by Delivering Planned Care” by L. Gordon Moore, M.D.
This method of providing healthcare (managing the presenting problem), often contributes to the lack of high-quality, complete care being provided to individuals in need. In spite of the dedication, hard work and professionalism of healthcare providers, gaps in care and health disparities still exist and will not be closed with greater amounts of professionalism, hard work or dedication.
To eliminate health disparities and improve functional and clinical outcomes, health care organizations must change the way they deliver care. Implementation of the Planned Care Model calls for a transformation in the delivery of care. The transformation affects how:
Providers such as doctors, dentists, social workers, and nurses deliver care
Patients understand and participate in managing their own care
Communities learn to strengthen the provider-patient partnership
This model of care involves a heavily researched set of components that, when successfully implemented in practice, leads to improved interactions between informed, activated patients and a prepared, proactive care team.
The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative.
Differences in Reactive Care vs. Planned Care after the implementation of the Planned Care Model
Consider the following scenario
Mr. Rivera is a 42 year old man with a history of diabetes and depression. You have seen him on and off for 2 years. You have had him on Metformin and Effexor and now his A1c is 14. You talk to him about insulin and he says he knows about it because he gives it to his mother. You give him a script for insulin and syringes and make a referral to the diabetes educator. You tell him to come back in two weeks.
Reactive Care vs. Planned Care
|That diabetic patient comes back in after 6 months feeling terrible.
||Every month, a report is run of all patients with an A1c greater than 10 who have not been in for the last three months.
|Staff looks for the chart.
||The diabetic patient discussed above is on the list. The MA calls the patient.
|The last note is read and staff looks for lab results.
||The patient tells the MA that he is afraid to take the insulin because his friend told him it would make him fat.
|The patient is asked how he feels on the insulin.
||After reassuring the patient, the MA makes and appointment with the Clinical Diabetes Educator.
|The patient informs staff that he didn’t start on the insulin. He says “My friend told me it is going to make me fatter”.
||The CDE instructs the patient and he starts on insulin. An appointment is made to see the doctor in one month.
|Staff also finds out that the patient did not go to the diabetes educator because he was ashamed that he was not doing what the doctor told him.
||MA or CDE calls the patient once a week to see how insulin administration is going.
|Staff orders a stat A1c and it is now 16.
||Patient comes in for appointment one month later. A1c is drawn while patient is waiting to see the doctor. It is now 10.
|Provider is 15 minutes into the visit and it’s just beginning.
||You have the opportunity to address other issues during the patient visit.
More about Planned Care Model Change Concepts can be found at http://www.improvingchroniccare.org/change/model/components.html