Planned Care Survey

Academic Chronic Care Collaborative Assessment of Chronic Illness Care Education (ACIC-E) Version 1.0 Please complete the following information about you and your educational program(s). This information will not be disclosed to anyone besides the ACCC Leadership team, although de-identified information may be aggregated and shared with other members of this collaborative. We would like to get your phone number and e-mail address in the event that we need to contact you/your team in the future. Please also indicate the names of persons (e.g., team members) who complete the survey with you. Later on in the survey, you will be asked to describe the process by which you complete the survey. Your name: Date: ______/______/______Month Day Year Organization & Address: Names of other persons completing the survey with you: 1.

Your phone number: (______) ______- ______Your e-mail address:

Directions for Completing the Survey This survey is designed to help educational programs and teaching practices move toward the “state-of-the-art” in teaching targeted learners how to manage chronic illness. The results can be used to help your team identify areas for improvement. Please answer each question below from the perspective of the practice site. If you have more than one practice site, please complete one form for each site.

1. Name and type of site (e.g., University Family Health Center resident-faculty practice) ______

2. Please specify disease or condition (e.g. Diabetes) ______

3. Please specify targeted learners (e.g. pediatric residents, nursing students, 4 th year medical students). In some cases more than one type of learner may be involved. ______

Directions for subsequent pages: For each row, circle the point value that best describes the level of care and education that currently exists in the site and condition you chose, with the targeted learners. The rows in this form represent key aspects of chronic illness care education. Each aspect is divided into levels showing various stages in improving chronic illness care education. The stages are represented by points that range from 0 to 11. The higher point values indicate that the actions described in that box are more fully implemented.

Finally, sum the points in each section (e.g., total part 1 score), calculate the average score (e.g., total part 1 score / # of questions), and enter these scores in the space provided at the end of each section. Then sum all of the section scores and complete the average score for the program as a whole by dividing this by 7.

For more information about how to complete the survey, please contact: Judith L. Bowen, MD, [email protected]

1 Assessment of Chronic Illness Care Education, Version 1.0

Part 1: Organization of the Healthcare Delivery System. Education about chronic illness management can be more effective if the overall system (academic health center) in which care is provided is oriented and led in a manner that allows for a focus on chronic illness care.

Components Level D Level C Level B Level A Overall Education …does not exist or there is a little …is reflected in training program …is reflected by clear training …is reflected in the institution’s Leadership in Chronic interest. vision statements and/or curricular program leadership and specific educational priorities, receives Illness Care plans, but no resources are dedicated resources (dollars and necessary resources, and specific specifically earmarked to execute personnel). people are held accountable. the work of educating trainees. Score 0 1 2 3 4 5 6 7 8 9 10 11 Improvement Strategy …is ad hoc and not organized or …utilizes ad hoc educational …utilizes systematic education …utilizes systematic educational for Chronic Illness supported consistently. approaches for targeted chronic strategies for targeted chronic strategies for targeted chronic Care education conditions as quality of care issues conditions as quality of care issues conditions proactively in meeting emerge. emerge. educational and quality of care goals Score 0 1 2 3 4 5 6 7 8 9 10 11 Incentives and …are not used to influence …are used to influence learners’ …are used to support patient care …are used to motivate and Regulations for learners’ clinical performance management decisions for chronic goals and influence learners’ care empower learners to support patient Chronic Illness Care goals. illness care. decisions care goals.

Score 0 1 2 3 4 5 6 7 8 9 10 11 Senior Health System …discourage enrollment of the …do not make improvements to …encourage educational programs …visibly participate in efforts to Business Leaders chronically ill in residency chronic illness care a priority. to make improvements to chronic improve chronic care education and (teaching) practices illness care a priority but do not clinical care delivery, providing the provide resources or support needed resources and support to achieve explicit health system goals 9 10 11 Score 0 1 2 3 4 5 6 7 8

Total Health Care Organization Score ______Average Score (Health Care Org. Score / 4) ______

Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 2 Part 2: Community Linkages. Linkages between the health delivery system (or learner-provider practice) and community resources play important roles in the management of chronic illness. Components Level D Level C Level B Level A Demonstrating for …is not done systematically. …is limited to using a list of …is accomplished through a … is accomplished through active learners’ the identified community resources in dedicated teaching activity that coordination between the clinical importance of linking an accessible format when the issue illustrates a systematic approach education program, community patients to outside arises in the care of a patient. for ensuring resident providers and service agencies and patients to resources patients make maximum use of systematically integrate learning community resources. into residents’ daily practice in caring for patients Score 0 1 2 3 4 5 6 7 8 9 10 11 Partnerships with …do not exist. …are being considered by the …are formed ad hoc to develop …are actively sought to develop Community teaching practice but have not yet supportive programs and policies. formal supportive programs and Organizations been implemented. policies across the entire system such that trainee exposure is integral to his/her education. Score 0 1 2 3 4 5 6 7 8 9 10 11 Learner assessment of …relies upon patients or families …is expected as part of the is included in dedicated teaching …is routinely accomplished by the Patients’ Community bringing the concern or activity to assessment of all patients with activities but support for care team as a task delegated to the Support and the learner’s attention chronic conditions but remains the accomplishing the assessment is most appropriate team member Community-based responsibility of the learner not yet a systematic part of the care with follow-up to provide resources activities. provider team’s assessment of patients as needed to patients, and includes dedicated teaching activities to support learners in integrating these patient assessments in care planning Score 0 1 2 3 4 5 6 7 8 9 10 11

Total Community Linkages Score ______Average Score (Community Linkages Score / 3) ______

Part 3: Practice Level. Several components that manifest themselves at the level of the individual learner provider practice (e.g. individual clinic) have been shown to improve chronic illness care. Educational programs should address these characteristics, which fall into the general areas of self- management support, delivery system design issues that directly affect the practice, decision support, and clinical information systems. Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 3 Part 3a: Self-Management Support. Education about effective self-management support can help patients and families cope with the challenges of living with and treating chronic illness and reduce complications and symptoms. Components Level D Level C Level B Level A Assessment of …is not routinely done …is done informally by patients ….is formally completed by the ….is formally completed by the patients’ experience in volunteering to complete comment practice organization but results are practice organization with a and satisfaction with cards or other similar mechanisms not routinely shared and discussed specific focus on needs of and the practice following a care episode in with learners satisfaction with chronic illness learners’ practices care, with results routinely discussed with learners as an integral part of the teaching curriculum Score 0 1 2 3 4 5 6 7 8 9 10 11 Assessment and …are not done. …are expected. …are completed in a standardized …are regularly assessed, recorded Documentatio manner by the practice team. in standardized form, and linked to n of Patients’ a treatment plan available to Self- practice and patients. Management 0 1 2 3 4 5 6 7 8 9 10 11 Needs &Activities Score Self-Management …are limited to the distribution of …are available by referral to self- …are provided by trained clinic …are provided by clinic staff Support strategies patient information (pamphlets, management classes or educators staff who are designated to do self- affiliated with each practice, booklets). and learners may attend (but are management support, affiliated trained in patient empowerment not required to do so). with each practice, and offer to and problem-solving include learners’ in delivering this methodologies, and systematically care include learners in delivering this care. Score 0 1 2 3 4 5 6 7 8 9 10 11 Effective Behavior …is not part of the teaching …is taught through the informal …is formally taught on a elective …is routinely taught as an integral Change Counseling program distribution of handouts or other basis only to interested learners part of the teaching curriculum and written or electronic information separate from the teaching practice expected to be applied when the topic arises systematically in the care learners deliver. Score 0 1 2 3 4 5 6 7 8 9 10 11 Faculty Development ….is not provided …is available on a voluntary basis …is offered periodically as a …is expected of all teaching in Self-Management for interested faculty CME-type activity to key teaching faculty with clinical supervision Support faculty who have clinical responsibilities and routinely supervision responsibilities for provided to assure faculty are Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 4 learners current and proficient with teaching and role modeling self- management Score 0 1 2 3 4 5 6 7 8 9 10 11

Total Self-Management Score______Average Score (Self Management Score / 5) ______

Part 3b: Decision Support. Effective chronic illness management programs assure that providers have access to evidence-based information necessary to care for patients--decision support. Components Level D Level C Level B Level A Evidence-Based …are not discussed or used in the …are available but are not …are routinely discussed through a …are routinely discussed and Guidelines teaching practice routinely discussed in learning dedicated teaching activity critiqued in a dedicated teaching sessions about care delivery. (including use of evidence in activity (including use of evidence guideline development and clinical in guideline development and judgment in applying guidelines) clinical judgment in applying and guidelines are available for guidelines); guidelines are application in practice . integrated into care through reminders and other proven provider behavior change methods. Score 0 1 2 3 4 5 6 7 8 9 10 11 Learner Exposure to …is primarily through traditional …is achieved through specialist …is achieved through systematic …includes specialist leadership and Specialists involved in referral or specialty rotations. educational consultation on specialist involvement in primary specialist integration into the Improving Primary specific patients care team care and training, . primary care delivery team caring Care for primary care patients, where learners are members of the care team Score 0 1 2 3 4 5 6 7 8 9 10 11 Self-directed Learning ….is expected but initiated entirely …is expected with structured …is expected with structured …is expected for all learners and by the learner without faculty teaching sessions on critical teaching sessions on critical includes structured teaching session guidance appraisal of the medical literature appraisal of the medical literature on critical appraisal of the medical with learner participation based on directly applied to clinical literature to address questions about interest and availability questions related to chronic chronic disease management, conditions, with learner application of learning to questions participation based on interest and arising in practice, learner-centered availability teaching sessions to report findings, and faculty role modeling of these behaviors 9 10 11 Score 0 1 2 3 4 5 6 7 8 Faculty Development ….is not provided …is available on a voluntary basis …is offered periodically as a …is expected of all teaching Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 5 Components Level D Level C Level B Level A in Critical Appraisal for interested faculty CME-type activity to key teaching faculty with clinical supervision of the Medical faculty who have clinical responsibilities and routinely Literature & supervision responsibilities for provided to assure faculty are Application to learners current and proficient with teaching Chronic Care and role modeling critical appraisal skills and self-directed learning Score 0 1 2 3 4 5 6 7 8 9 10 11 Total Decision Support Score______Average Score (Decision Support Score / 4) ______Part 3c: Delivery System Design. Evidence suggests that effective chronic illness management involves more than simply adding additional interventions to a current system focused on acute care. It may necessitate changes to the organization of practice that impact provision of care. Components Level D Level C Level B Level A Practice Team …does not include learners and is …includes learners and is …includes learners and is assured …is assured by teams that include Functioning not addressed. addressed by assuring the by regular team meetings that learners who meet regularly and availability of individuals with learners attend to address have clearly defined roles including appropriate training in key guidelines, roles and patient self-management education, elements of chronic illness care. accountability, and problems in proactive follow-up, and resource chronic illness care. coordination and other skills in chronic illness care, with follow-up team function assessment, feedback, and reflection Score 0 1 2 3 4 5 6 7 8 9 10 11 Resident (or other …is not recognized locally or by …is assumed by the educational …is assured by the appointment of …is guaranteed by the appointment learner) Leadership the education program. program to reside in specific a resident (or other learner) team of a resident (or other learner) team on the Practice Team organizational roles such as leader but the role in chronic illness leader who participates in assuring hospital-based ward team leader, is not defined. that roles and responsibilities for but not in the ambulatory practice chronic illness care are clearly setting. defined. Score 0 1 2 3 4 5 6 7 8 9 10 11 Planned Visits for …are not used. …are occasionally used for …are an option for interested …are used for all patients in the Chronic Illness Care complicated patients. patients and learners but require target practice/population and in the Learners’ learner initiative to carry out the include regular assessment, practice planning and delivery preventive interventions and attention to self-management support with learners as integral members of the planned visit practice team. Score 0 1 2 3 4 5 6 7 8 9 10 11 Patient Treatment …are achieved through a …are established collaboratively …are established collaborative …are established collaborative and Plans traditional provider-centered with patients/families and with patients/families and include self-management as well as Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 6 Components Level D Level C Level B Level A (faculty-learner) approach learners/faculty, addressing self- appropriate team members (e.g. clinical management. Non- management and clinical goals. physicians, nurses, pharmacists, physician team leadership provides Plans between visits depend on social workers, learners) protocol driven follow-up that faculty/learner tracking and addressing self-management and guides care at every point of initiation. clinical goals. Plans between visits service. Registries and protocols can be delegated to non-physician guide support for learners’ patients team members when the learner is not in the practice, keeping learner team members informed of patient’s progress

Score 0 1 2 3 4 5 6 7 8 9 10 11 Coordination of Care …is not a priority. …depends on written …between learner PCPs, …is a high priority and all chronic for patients of part- communication between learners specialists and other relevant disease interventions include active time learner providers and consultants directly, and providers is a priority, is initiated coordination between primary care, between learners and their practice by the learner PCP but is arranged specialists and other relevant faculty supervisors and managed by the care team. groups, including systematic support for resident patients when the resident is not in the practice. Score 0 1 2 3 4 5 6 7 8 9 10 11 Faculty Development ….is not provided …is available on a voluntary basis …is offered periodically as a …is expected of all teaching in Teamwork and for interested faculty CME-type activity to key teaching faculty with clinical supervision System Design faculty who have clinical responsibilities and routinely supervision responsibilities for provided to assure faculty are learners current and proficient with teaching and role modeling team membership and understanding the roles and functions of other team members and when to call on them to deliver care Score 0 1 2 3 4 5 6 7 8 9 10 11 (From Previous Page)

Total Delivery System Design Score______Average Score (Delivery System Design Score / 6) ______

Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 7 Part 3d: Clinical Information Systems. Timely, useful information about individual patients and populations of patients with chronic conditions is a critical feature of effective programs, especially those that employ population-based approaches. Components Level D Level C Level B Level A Registry (list of …is not available. …includes name, diagnosis, …allows learners to sort by clinical …is tied to guidelines which patients with specific contact information, learner PCP, priorities, but depends on learner provide prompts and reminders conditions) for and date of last contact either on motivation to study his/her own about needed services and regular practice paper or in a computer database. population performance reports to learners with discussion and reflection on disease management Score 0 1 2 3 4 5 6 7 8 9 10 11 Reminders to Learner …are not available. … include general notification of …includes indications of needed …includes specific information for Providers the existence of a chronic illness, service for populations of patients the team about guideline adherence but does not describe needed through periodic reporting. at the time of individual patient services at time of encounter. encounters and for the practice as a whole Score 0 1 2 3 4 5 6 7 8 9 10 11 Practice Performance …is not available or is non-specific …is provided at infrequent …occurs at frequent enough …is timely, specific to the resident Feedback to the team. intervals and is delivered intervals to monitor performance team, routine and personally impersonally. and is specific to the resident delivered by a respected opinion team’s population. leader to improve team performance. Score 0 1 2 3 4 5 6 7 8 9 10 11 Information about …is not available. …can only be obtained with …can be obtained upon request but …is provided routinely to residents Relevant Subgroups special efforts or additional is not routinely available. to help them deliver planned care. of Patients Needing programming. Services

Score 0 1 2 3 4 5 6 7 8 9 10 11 Faculty Development ….is not provided …is available on a voluntary basis …is offered periodically as a …is expected of all teaching in Clinical for interested faculty CME-type activity to key teaching faculty with clinical supervision Information System faculty who have clinical responsibilities and routinely supervision responsibilities for provided to assure faculty are learners current and proficient with teaching and role modeling use of population data to optimize care delivery to patients with chronic conditions Score 0 1 2 3 4 5 6 7 8 9 10 11

Total Clinical Information System Score______Average Score (Clinical Information System Score / 5) ______

Integration of Educational Components for Teaching the Chronic Care Model Integration of Chronic Care into Education Components Level D Level C Level B Level A Education Champion …does not exist …can be identified but is not …is identified and an integral …has been empowered to develop for teaching about empowered to make changes in the member of the training program and implement a training chronic care curriculum or design of the training leadership team curriculum designed to achieve program specific learning objectives in chronic care management linked to performance outcomes Score 0 1 2 3 4 5 6 7 8 9 10 11 Chronic Care …does not exist …exists as part of other existing …includes instruction on the gap …includes didactic and Curriculum curricular activities but is limited to between existing care and what is experiential methods to instruct the medical management of the possible, and addresses the learners about the quality gap, chronic condition components of the Chronic Care evidence supporting the chronic Model care model, the model components, and experience in practice using chronic care practice improvement strategies Score 0 1 2 3 4 5 6 7 8 9 10 11 Learner Education for …is provided sporadically. …is provided systematically …is provided using innovative, …is provided using innovative Chronic Illness Care through traditional educational practice-centered methods (e.g. practice-centered methods, and conferences. academic detailing). reinforced by involvement in quality improvement and includes

Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 9 Components Level D Level C Level B Level A training in chronic illness care methods such as population-based management, and self-management support. Score 0 1 2 3 4 5 6 7 8 9 10 11 Learner involvement …exists but roles and …exists with defined roles but care …includes explicit instruction in …includes explicit instruction in in Inter- responsibilities are assumed and coordination is lacking and teamwork and orientation to roles teamwork, orientation to roles and professional not discussed or planned physician assumes s/he is and responsibilities of each team responsibilities of team members, Teams responsible for clinical tasks member in delivering care regular team function assessment, and support for innovation in team care delivery 0 1 2 3 4 5 6 7 8 9 10 11 Score

Components Level D Level C Level B Level A Practice analysis and …does not exist …is encouraged but relies upon …is a systematic part of the …is a systematic part of the reflection individual learners to analyze and teaching curriculum and driven by teaching curriculum, driven by improve his/her own practice population reports from the population reports from the patterns learners’ practice learners’ practice, including error identification, analysis, and reduction action plans Score 0 1 2 3 4 5 6 7 8 9 10 11 Learner participation …does not exist …is encouraged by asking learners …is a routine part of the teaching …is a routine part of the teaching in practice to identify problems and share curriculum but does not include practice where learners are improvement them with practice leadership experiential application of rapid instructed in rapid-cycle cycle change methods improvement, identify problems and apply PDSA methods to test improvements, and implement successful changes in their practices Score 0 1 2 3 4 5 6 7 8 9 10 11

Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 10 Total Integration Score (SUM items): ______ Average Score (Integration Score/6) = ______

Adapted from The Assessment of Chronic Illness Care 3.5 Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative 11 Briefly describe the process you used to fill out the form (e.g., reached consensus in a face-to-face meeting; filled out by the Education team leader in consultation with other team members as needed; each team member filled out a separate form and the responses were averaged).

Description: ______

______

Scoring Summary (Bring forward scoring at end of each section to this page)

Total Org. of Health Care System Score ______Total Community Linkages Score ______Total Self-Management Score ______Total Decision Support Score ______Total Delivery System Design Score ______Total Clinical Information System Score ______Total Integration Score ______

Overall Total Educational Program Score (Sum of all scores) ______Average Educational Program Score (Total Program /7) ______