The Chronic Care Model

The principle behind the Model is that the current system, which is designed to handle short-term illnesses, injuries and infections, cannot meet the population-based and planned care needs of the chronically ill.

Beginning in 2000, the Ministry of Health in British Columbia adopted The Chronic Care Modelfor use in its quality improvement work. It adapted the Model to fit the expanded role of government and community in the Canadian health care system and named it The Expanded Chronic Care Model. Since then, other provinces that include Alberta, Saskatchewan, and Ontario are embarking on similar quality improvement work. These provinces are also using derivatives of The Chronic Care Model to redesign their health care infrastructures.

This redesign work requires a multi-disciplinary health care team with the patient at the centre. Information systems are used not only to facilitate individual care but to manage populations of patients by tracking their evidence based care needs and then proactively delivering that care through planned visits, group visits, and telephonic and web-based care. The multi-disciplinary team is supported by evidence based decision making tools coupled with care co-ordination agreements involving other providers, all of which results in collaborative shared care plans between the team and the patient. It is essential the team be afforded sufficient time to deliver evidence-based preventive and chronic care and ensure active, sustained follow-up to make certain patients are able to enact their care plans. The system ensures self -management support be delivered at every encounter so that patients are empowered to be self managers of their care. All of these innovative re-design efforts are supported by: communities that support healthy public policy; physical and social environments that encourage healthy lifestyles; and, resources that compliment the care delivered by the health care system.

Learning collaboratives are an essential aspect of this quality improvement. These collaboratives (based on the Breakthrough Series methodology developed by the Institute for Healthcare Improvement) bring together health care teams for a one year improvement process that teaches how to implement the tenants of The Chronic Care Model. This is accomplished by using a rapid cycle improvement methodology called the Model for Improvement (developed by Associates for Process Improvement). Collaboratives are being used extensively in a number of provinces. Province wide registries are being developed allowing providers to manage populations of chronically ill patients. The data collected from these registries are used to monitor performances of the teams and provide province-wide outcomes data. Community-based self-management programmes are being implemented to compliment the support delivered by frontline providers.

There is however one piece of the puzzle missing: appropriate reimbursement.

In order to guarantee that this system change sustains, it must be financed properly. The current fee for service reimbursement was designed to support brief acute care visits. It does not adequately reimburse for the required visit types and the intensity of care that is needed for chronically ill patients. It is unrealistic to expect our front line providers to work harder to meet the demands of this new system while compensating them through a structure designed for a very different type of care delivery.

Currently, British Columbia and parts of the United States are engaging in demonstration projects looking at new reimbursement models for chronic illness care. These efforts are in their infancy, however. Pay for performance while a positive step, is a Band-Aid on the current reimbursement system.

As a nation, it is imperative that we move quickly to implement successful reimbursement mechanisms that promote comprehensive chronic care whether it is in the provider office, over the telephone, through email, or other delivery mechanisms. Without an appropriate reimbursement system in place, we will continue to encourage brief face to face visits that are symptom directed, and typically result in a prescription and the doling out of patient education pamphlets.

So, in order to continue to move forward in quality improvement efforts here in Canada, it is imperative that all parts of the current system undergo reconstruction. As stated earlier, nothing short of a complete system re-design will meet the needs of Canada’s chronically ill patients.