AAMC Reporter: December 2005

Chronic Care Collaborative Brings Focus on Patient's Role in Treatment to Teaching Hospitals

By Anne Blank, Special to the Reporter

Daniel Federman, M.D., and Joan Lugovich, R.N., at VA Connecticut Healthcare System Primary Care showing a patient how to read his blood pressure at home

Mindful that her between-meal snacks were pushing her blood-sugar levels to potentially dangerous levels, the diabetic patient at Southern Illinois University School of Medicine (SIU) understood what she would have to do when she went home from the hospital: stop snacking. And when a nurse called her two weeks later to see how things were going, the patient happily reported that, yes, she had indeed given up snacks.

It was a victory for the patient, to be sure, but it might not have happened without a new approach at SIU that encourages patients with chronic diseases to become more actively engaged in their own treatment. The effort lies at the heart of an 18-month cooperative program involving SIU and 21 other medical schools and teaching hospitals across the country.

Known as the Academic Chronic Care Collaborative, the program was established last spring by the AAMC's Institute for Improving Clinical Care (IICC) and the Robert Wood Johnson Foundation. It is based on a model developed in the early 1990s by Edward H. Wagner, M.D., M.P.H., director of Improving Chronic Illness Care at the MacColl Institute for Healthcare Innovation in Seattle, and colleagues.

The collaborative represents the first concerted effort to apply the model to teaching hospitals. The model assumes that because patients must live with their own illnesses, they can help themselves considerably by having a central role in the health-related decision making that affects them. After all, says David Stevens, M.D., director of the IICC and the AAMC's vice president for clinical care improvement, "No one is more committed to controlling one's diabetes than the person who has it."

Adds Maureen Francis, M.D., associate professor in SIU's department of medicine, about the diabetic woman who stopped having snacks: "It's different if we preach to people. We should probably all make a lot of changes in our lives that we don't."

Enabling the diabetic woman to act on what she had learned about snacking and her health problems gave her "a chance to take ownership of the problem."

Indeed, chronic illnesses such as diabetes, arthritis, cardiovascular diseases, and cancer kill some 2 million Americans every year, according to the National Center for Chronic Disease Prevention and Health Promotion, part of the Centers for Disease Control and Prevention (CDC). And for those who survive, chronic diseases produce major complications that can lead to higher health care costs.

In recent years, a number of factors have converged to produce a rethinking, if not yet an overhaul, of how chronic diseases should be managed. For one thing, better health care in general means that people with chronic diseases are living longer than ever. At the same time, high health care costs and mounting administrative burdens for providers are curtailing the amount of time that physicians spend with some of the very patients who may need it the most.

More than 75 percent of the $1.4 trillion spent each year on health care in the U.S. is funneled toward treating chronic diseases, according to the CDC.

Changing the Emphasis

At Vanderbilt Medical Center, which is looking at diabetes as part of the Academic Chronic Care Collaborative, there are questions about the appropriateness of a traditional acute care emphasis in resident training when it comes to caring for chronically ill patients. "We need to do a better job of training our residents in how to think about chronic illnesses," says G. Waldon Garriss, III, M.D., M.S., associate chair for ambulatory education at Vanderbilt, and associate director of both medicine-pediatrics and the medical center's internal medicine residency program.

"We basically still have a system in this country that is an acute care system, which does a poor job of trying to care for people with chronic illnesses," Garriss said.

At the Veterans Affairs Connecticut Healthcare System (VA Connecticut), which is affiliated with Yale University and the University of Connecticut, doctors are encouraging patients to participate in their own care by ensuring that they have the tools to do so. For example, patients with hypertension are encouraged to check their own blood pressure at home. They receive a blood-pressure monitoring machine to take with them if they do not already have one, says Daniel Federman, M.D., staff physician in the department of internal medicine at VA Connecticut West Haven campus.

Michael Ebert, M.D., chief of staff, Veterans Affairs Connecticut Healthcare System

VA Connecticut is the only institution in the Academic Chronic Care Collaborative that is examining post-traumatic stress disorder (PTSD) among veterans. As a frequently diagnosed illness at VA Connecticut — and one that can severely impair daily functioning for years if victims do not obtain proper treatment — PTSD represents a critical area for study, says Michael Ebert, M.D., chief of staff at VA Connecticut.

Because PTSD symptoms can vary greatly and be difficult to diagnose, clinicians at VA Connecticut have been using the chronic care model to rethink management of the disorder. In the first phase of their work in the collaborative, Ebert notes, they decided to devote at least six months to analyzing and refining PTSD screening tools.

In the second phase, they will compare standard treatments for PTSD with a new treatment — cognitive processing therapy — that the hospital recently began to administer, according to Dolores Vojvoda, M.D., director of the PTSD-Anxiety Firm, a unit at VA Connecticut that houses the clinical neuroscience division of the National Center for PTSD. She says the new treatment combines cognitive behavioral and exposure therapies.

Along with patient self-management, the chronic care model encourages providers to be far more proactive in their approach to treatment. Previously, for example, the SIU diabetic patient might well have had no further contact with her health care providers after her discharge until her next doctor's appointment — unless she initiated it herself. Under the chronic care model, however, providers closely monitor patients' records to ensure that critical tests and exams are performed before serious problems arise.

Britt Crewse, M.H.A., associate operating officer for ambulatory services at Duke University Medical Center

At Duke University Medical Center, about 2,500 diabetic patients are participating in the Academic Chronic Care Collaborative through the hospital's outpatient clinic and community- and family-medicine program. Says Britt Crewse, M.H.A., associate operating officer for ambulatory services at the hospital: "We are ensuring that we're providing the right exams, that we are asking questions, and that we are reminding patients that they need these tests."

Cincinnati Children's Hospital Medical Center is the only pediatric institution in the collaborative, as well as the only one focusing solely on asthma. According to Lisa Crosby, R.N., C.P.N.P., asthma case-management nurse practitioner in the Pediatric Primary Care Center, clinical resident education in the days before the collaborative concentrated mainly on well-child visits. Under the chronic care model, residents now are being assigned to asthma patients, whom they will follow throughout their residencies.

"They will be able to learn more about asthma patients and what kind of care is best for those patients," Crosby says. Overall, says Francis of SIU, participants in the Academic Chronic Care Collaborative have encountered few obstacles in implementing the chronic care model, with time constraints being the biggest roadblock for some. The time factor is especially troublesome for institutions that are still in the process of switching to electronic patient files, which streamline the process of identifying patients who are due for tests or treatments.

Contact Us    © 1995-2008 AAMC    Terms and Conditions    Privacy Statement