Turning the Corner on Chronic Disease Management

Dr. David LinkCambridge Health Alliance decided that a new approach was needed to help patients with asthma and other chronic illnesses manage their disease more effectively. The Alliance committed to utilizing the planned care model, developed by Dr. Ed Wagner and his colleagues at the MacColl Institute for Healthcare Innovation.

The Planned Care Model envisions productive interactions between a prepared provider team and an informed, activated patient. Providers utilize evidence-based guidelines, and are supported by information technology and community resources. These elements are all part of a health care institution that has made the effective management of chronic disease a central part of its mission.

“We and most other institutions are not very effective, and thereís I think ample evidence either asking individual patients, or looking at the outcomes on how theyíve faired in the health care system to suggest we donít do a job worthy of their illness and worthy of the amount of resources put into it,” says Dr. David Link.

According to Cambridge Health Alliance CEO, Dennis Keefe, “The whole approach with planned care is to be working with patients, helping them develop a plan to manage their disease, making sure they stick to that plan on an ongoing basis, making sure they understand what that plan is, making sure they actually have a copy of that plan so if they go anywhere they can present this is the treatment plan that Iím on.”

The Alliance has adopted the planned care model across many of its primary care practices. Instead of being reactive and treating chronic illness when it becomes acute, providers and patients are encouraged to become proactive by managing symptoms, maintaining a healthy lifestyle, and preventing hospitalizations.

Technology plays a critical role in the program. For example, the Alliance has implemented a disease specific database containing information on its youngest patients with asthma. Not only can the providers within the Alliance Network access the information but so can other institutions, including nurses in the Cambridge school system.

“Itís a connector for everybody. It reaches into the school where the child is during the day, it reaches into the office where we treat them, it reaches into the pharmacy where they get their medications, it connects to the Healthy Homes Program. It goes into the emergency department, if they have to turn up in the emergency department. It reports to the physician in an aggregate way, how theyíre doing with their patients, what elements of the illness havenít been addressed,” according to Dr. Link.

Says school nurse Sharon Jones, “The physician will only see the child when the child is ill. We maintain the illness. We're able to be hooked up into the computer and we're able to see what kind of medications the child's on so everyone's on the same page.”

The Alliance has also established a Healthy Homes project which allows trained case workers to visit the homes of asthma patients to identify molds and other problems that trigger attacks, and then help clean up the environment the child lives in.

To provide parents with valuable information they can use at home, group meetings with other patients and families are regularly offered.

“It was very, very helpful to hear from the other parents their experience and what itís like, and for me to kind of expect or prepare myself in case I get into those situations. It was very helpful for me to know those thoughts and what other people go through, not just him alone,” says Lomalee Houston whose son has asthma.

Dr. David LinkEvery parent is provided with written instructions identifying the medications his or her child is on plus telephone numbers to call in case of emergency. To ensure a continuum of care school nurses are provided with the same information, just in case they are unable to access the Allianceís database.

Cambridge Health Alliance is making significant changes in how it treats patients with chronic diseases. Preliminary results show a dramatic decrease in the usage of the emergency department and hospitalizations by asthmatic children.

While Dr. Link is happy with these early results heís also keeping his eye on a longer-term goal.

“We havenít solved chronic illness. However, weíre working very, very hard on this. Weíve got to get there. There is no choice. Itís an absolute imperative.”

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