Chronic care toolkit (AAFP annual scientific assembly)

Logs of patient progress, support for self-care and connections to community resources can improve disease management.

By Susan J. Landers — Posted Nov. 20, 2006

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Physicians' waiting rooms fill with patients who have chronic medical conditions -- diabetes, arthritis, heart disease, depression, pain. But today's medical system is geared up to treat acute conditions.

It's time for system change, said physicians at the American Academy of Family Physicians' annual scientific assembly held in Washington, D.C., Sept. 27 to Oct. 1.

Granted, doctors have been taking care of patients with chronic illnesses for a long time, said Theodore Ganiats, MD, professor of family and preventive medicine at the University of California, San Diego. "But the data show we aren't doing a very good job."

For example, only 27% of patients with hypertension are adequately controlled, and only 25% of those with depression are treated.

"It's not because we don't care, or aren't hard working or we don't know what we're doing, but it's that the systems we are functioning in are not the most efficient," he said.

A panel of physicians led by Dr. Ganiats discussed ways to bring those systems in line with the goal: chronic illness management. They used a model developed in 1998 by Edward Wagner, MD, MPH, director of the MacColl Institute for Healthcare Innovation in Seattle, as a framework to establish high-quality, patient-centered chronic disease care. The model weaves together the use of community resources, the reorganization of office systems and support for patients.

Chronic disease care is about what takes place between office visits, said Joseph Scherger, MD, MPH, professor of family and preventive medicine at the University of California, San Diego. "Patients with chronic illness live with chronic illness every day. And every day a diabetic patient makes several decisions about what they are going to do about their diabetes."

The key to proper management is not to take over for patients but to make them integral players in their care, Dr. Scherger said.

This goal can be achieved in different ways and with different tools, he said. In a poor area of California, community health workers visit patients at home to educate them and make sure they are taking their medications. In Dr. Wagner's model, patients were contacted via the telephone. And he found that disease control soared from about 25% of patients to 75% and 80%.

Others may find success in group visits. Edward J. Shahady, MD, medical director for the diabetes master clinician program, an initiative of the Florida Academy of Family Physicians Foundation, conducts group visits and has trained many Florida physicians to do the same.

He believes such visits are the wave of the future. He chose diabetes as a kick-off for this approach because the disease is complex and could serve as the "poster child for other chronic diseases." Dr. Shahady shared some of his lessons learned with physicians at the conference.

Patients likely fall into one of three groups, he said. There are the exemplary patients who watch their diets, exercise and have their disease under good control. They probably don't need to come in for group visits -- although a few could serve as examples to the others. Other patients might lack transportation and would find it difficult to attend meetings. But there is a third group who are struggling with adequate control and could benefit from the additional contact with physician, staff and others who face the same challenges.

And patients do seem to benefit. "I won't feel alone with this condition," one patient told him. "I like the group visits because you learn so much from other people with diabetes," another said.

Charting these measures, whether with an electronic medical record or paper, is a good indicator of progress for physicians as well as patients, said Bruce Bagley, MD, AAFP's medical director for quality improvement.

The measures also could provide the evidence that a physician practices quality medicine, Dr. Bagley said.

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Works well with doctor?

[download pdf]

Patients can help track their satisfactory progress and see where they need improvement with report cards developed by Edward J. Shahady, MD, medical director for the diabetes master clinician program, an initiative of the Florida Academy of Family Physicians Foundation. Patients at group visits to his practice are given a personalized card, helping involve them in their own care.

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Getting everyone on the same page

Group visits for patients with the same chronic condition can cover a lot of disease management basics efficiently. For diabetes, for example, sessions can focus on diet, exercise, hypertension or foot care. Edward J. Shahady, MD, medical director of a diabetes master clinician program, offered these tips:

  • Prepare your office staff and explain the group visit will replace some routine visits.
  • Plan for the session to last about 2½ hours.
  • Invite about 10 patients; family members welcome.
  • Set the date well in advance to avoid scheduling conflicts.
  • Schedule a meeting every one to three months.
  • Spend the first 15 to 30 minutes taking vital signs and completing questionnaires. Plan for staff to speak for about an hour and for the physician to join in the second hour. Take the last 15 to 30 minutes to complete paperwork.

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Why women stop hormonal birth control

Some of the reasons given:

Side effects 37%
No further need 23%
Method difficulty 14%
Clinician recommended 9%
Other 17%
Total 100%

Source: The American Journal of Obstetrics and Gynecology, September 1998

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External links

More information about the AAFP's scientific assembly is online (link)

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