Institute for Healthcare Improvement: Innovation Community: Building an Effective "Planned Care" System for All Patients in Ambulatory Settings

Overview

The work of this Innovation Community continues in the new Redesigning the Clinical Office Practice Learning and Innovation Community.

The Building an Effective Planned Care System for "All Patients" in Ambulatory Settings Innovation Community concluded in spring 2005. Resources from this Community are available for reference on the "Meeting Materials" tab.

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Innovation Communities are groups of improvement-minded organizations working together and with IHI to explore new designs and novel solutions to improve care where best practices do not already exist or are not fully developed. Projects last for approximately 10 months under the guidance of an IHI panel of experts, and are open to IMPACT member organizations only.

The Problem

The Solution

An aging population and advances in medical care will produce a larger population of people suffering from more chronic conditions than ever before. Great strides have been made to improve outcomes for people with diabetes, congestive heart failure, and other chronic conditions using the Chronic Care Model (developed by Ed Wagner, MD, and colleagues at the MacColl Institute in Seattle, Washington, as part of the Improving Chronic Illness Care program). With a focus on one condition a time, providers can align services to help patients as never before.

The challenge now for providers is to design and implement a system that delivers excellent treatment and preventive care for all patients and across all diseases. Doing this just for people with chronic illness or for one condition at a time has proven to be feasible but not sustainable from either a service or financial perspective.

Patients and providers need better systems of care to address these challenges:

All patients, even those without chronic illness, need a customized plan for prevention and treatment
Effective care for people with multiple conditions cannot be sustained if care systems and guidelines are just "added" one on top of the other
Self-care management skills help patients to better function and well-being, no matter what their capacity or condition, but developing these skills for every patient is not yet built into the delivery system
Care for people with chronic conditions is most effective when office visits are combined with non-visit visit care, yet current payment systems generally cover only office based care
Information about patients must be available to all the providers that patients encounter in their communities

The Chronic Care Model and work in the Improving Chronic Illness Care program, which has developed further with IHI and the Bureau of Primary Health Care’s Health Disparities Collaboratives, provides a solid foundation for further design and innovation.

The next step is to build on this foundation by combining it with the best information on microsystems, resource planning, and patient-centeredness to create effective and sustainable systems of care that serve large populations of patients, such as typical office practice or community health center would serve.

Participating organizations will help test changes designed to achieve results that "raise the bar" — i.e., show outcomes and satisfaction for patients and providers that exceed previous results and can be achieved for thousands of people.

Areas of Focus

This Innovation Community will take what is known about chronic disease management, preventive care, and resource planning in office practices and test new methods that create measurable improvements in care across conditions, focusing on the following areas:

Patient self-management
A care team approach that makes the most of practice resources
Efficient use of clinical information
Innovation delivery system designs which match services to population needs and resource constraints, and allow "scale-up" to care for large populations

Aims

Participants will test new ideas in an effort to reduce pain, suffering, and helplessness among people with all conditions in ambulatory care. This initiative seeks to achieve measurable improvements in care, including:

Reduce patients’ symptoms and improve overall functioning
Increase patients’ confidence in self-management
Reduce use of acute care (ED visits and hospital admissions)
Maintain or reduce overall costs of care

To Participate

To join an Innovation Community, you must be a member of IHI's IMPACT network and have completed at least one successful improvement project within your organization. See IMPACT Network for more details about this exciting network of organizations collaborating for results.