Changing the paradigm for treating chronic illnesses

Physicians develop, implement new model

Photo of patients
Patients with chronic disease, such as diabetes, are given the skills to manage their disease to minimize complications.

For family practitioner Jim Nuovo, the chronic illness he was seeing in so many of his patients was giving him chronic frustration.

“Despite all the new technologies and treatments, my patients with chronic illnesses were still facing bad outcomes,” recalled Nuovo, a UC Davis professor of Family and Community Medicine. “They weren't making the progress I would have expected. In those with diabetes, for example, I wasn't seeing major reductions in complications like blindness or kidney failure.”

While it would have been easy to blame the patients for not following his instructions for diet, exercise and the like, Nuovo began to wonder if he wasn't part of the problem. Like virtually all physicians, he was schooled to treat short-term acute conditions — such as infection or injury — not long-term illnesses like diabetes, asthma and congestive heart failure, where there are no quick fixes.

Putting patients in charge

Things began to change in 2001 when the UC Davis Department of Family and Community Medicine received a two-year, $317,000 grant from the Robert Wood Johnson Foundation to teach its residents a new way to view chronic illness. Nuovo was the principal investigator for the teaching program, dubbed “Improving Chronic Illness Care.” The program was based on the work of a Seattle-area physician, Edward Wagner, whose “Chronic Care Model” calls for a systematic, proactive approach in which all patients are recognized as self-managers who make daily decisions that impact their condition. The model emphasizes empowering patients to understand the relationship between their daily decisions and living a healthy life that minimizes complications.

Nuovo said the new view amounts to a “paradigm shift.”

“It turned on light bulbs for all of us,” agreed Bridget Levich, a UC Davis clinical nurse specialist who was also a recipient of the Robert Wood Johnson grant. “The idea is to bring people in when they're not in crisis.” Rather it calls for inviting patients in to the office before serious problems have developed.

Reframing advice

The idea is also to change the way physicians interact with patients. Instead of giving a short lecture about what and what not to do — and warning them of dire consequences if directions aren't followed — doctors are encouraged to utilize a team approach that is patient centered.

Nuovo gave the example of a patient of his, a man in his 70s, who had trouble controlling his diabetes in part because he ate a bag of Hershey's Kisses every day. Instead of telling him the obvious — that he needs to bag the chocolate — Nuovo and the patient developed a plan to reduce his intake over time. “It took him three months to get down to five Hershey's Kisses a day,” Nuovo said. “He went from truly horrific control to acceptable control.”

As for Nuovo's teaching program, it was successful enough that senior leadership at UC Davis Health System established the UC Davis Chronic Disease Management Center in 2003. The purpose of the center, headed since its inception by Nuovo, is to integrate the new approach to chronic disease throughout UC Davis Health System.

Spreading the word

The first step was to introduce various facets of the new approach, such as group visits and planned visits to four offices in UC Davis Medical Group. Now an entire UC Davis Medical Group office in Rancho Cordova is being revamped as a model clinic to better serve its chronically ill patients. Sue Barton Ph.D., a member of the grant team, has facilitated weekly team meetings during which the group engineers the details of improving chronic illness care at the Rancho Cordova Clinic.

Knowing that it has reached epidemic numbers, the medical office's initial focus is on patients with diabetes. Gail Shamberg, a nurse coordinator brought in to help with the two-year project, states that one tool that is utilized is the Hemoglobin A1c test, which measures the average blood sugar level over the previous two to three months. “The beauty of this simple lab test is that it makes it easy to track how a patient is doing,” Shamberg said.

The Rancho Cordova office's seven physicians decided at the outset that they wanted to look at a specific subgroup of diabetic patients — those who hadn't come into the office in the previous six months. Identifying those patients wasn't terribly difficult thanks to the existence of an electronic patient registry. The registry contains general information from existing data sources, as well as specific information collected on each patient at the point of service. Clinicians can use the registry in a variety of ways, such as identifying groups of patients, tracking trends and identifying effective treatments.

Electronic registry helps

“In the old days, all we had was index cards,” commented Gerson Stauber, associate medical director at the Rancho Cordova office. “Now, with computers, it makes it easier to see what's going on with a patient and intervene when you need to.”

Out of the almost three hundred patients with diabetes contacted by telephone and in writing thirty-seven patients came in for a planned visit. In order to facilitate dialogue, patients were asked to get lab work — A1c, lipid panels and tests showing kidney function — done ahead of time.

Eighty percent did so, according to Shamberg. And a majority also took advantage of other services offered during the planned visits — including a chance to meet one-on-one with Levich, a diabetic nurse educator, and with a dietitian. All received information packets from clinic staff.

Expanding to other diseases

Similar planned visits are in the works for patients at the clinic with asthma and other chronic diseases. Progress will be assessed at the end of the two-year period, and if the model is deemed successful, it will be exported to the medical group's other primary care offices.

Stauber is supportive of the new direction. “I don't see any downside,” he said. “This is what we should have been doing all along.”

To learn more about the Chronic Disease Management Center please call (916) 734-0718.