Chronic Care Models, Medical Homes and Tools Which Make Them Work in Cardiac Rehab

From the "Retooling, Reframing and Redefining Cardiopulmonary Rehab" webinar

Description:
The Chronic Care Model (CCM) has been adopted by a multitude of healthcare organizations as a framework for the proactive management of patients with chronic conditions. A foundational strategy of the CCM, leading to improved outcomes, is the creation of productive interactions between an informed, activated patient and a prepared proactive practice team. Another key component includes health systems improvements involving decision support, self-management support, delivery system design and clinical information systems. Engaging community resources, rounds out the key strategies for providing more proactive chronic care management. This presentation will focus on specific strategies that align with the chronic care model and represent opportunities for cardiopulmonary rehab programs to serve as the “chronic care management center” for hospitals and health systems.

Topics:

I. Current models of care in health care reform and how they interrelate.

A. Chronic care model (how everything below fits underneath or relates to this)

1. medical home
2. accountable care organizations
3. bundled payments
4. THE CCDN

B. Population health management: key to all models

1. self-management support
2. informed, activated patient
3. prepared proactive practice team
4. productive interactions

C. Registries
D. Chronic disease management
E. Opportunities for rehabilitation programs

II. Rehabilitation programs as “chronic care management centers.”

A. Expansion of population served
B. Technologies to assist in chronic care management (overview)
C. Improving care coordination: bridging hospital to home and community

III. Improving the patient journey through the healthcare maze.

A. Higher health literacy
B. Self-management support
C. Community resources
D. Care coordination with outpatient services
E. Discharge clinic

Behavioral/Learning Objectives:

1. Define Accountable Care Organizations (or other health system business models) and the potential role of rehabilitation programs in aligning with desired outcomes: reducing avoidable healthcare utilization.
2. Describe population health management and how to target patients for chronic care management programs, as coordinated through rehabilitation programs.
3. Consider how rehabilitation programs can support the framework of the Chronic Care Model through patient self-management support, links to community resources and improved care coordination with providers and outpatient services.
4. Describe tools for population health management (registries, HRAs, etc.).