Fraser Health: Exploring a Model of Clinical Care Management Systems

by G. Ross Baker, Jean-Louis Denis, Agnes Grudniewicz, Charlyn Black | Nov 27, 2012
Full Report (PDF, 736 KB)

Key messages

  • The Fraser Health Authority is exploring health system transformation to enhance the delivery of healthcare services in light of growing demands and limited resources. This report outlines one strategic approach that would contribute to such change.
  • Expanding on current clinical improvement strategies, we propose a further, systematic development of “clinical care management (CCM) systems” incorporating physicians and other clinicians and resources to provide high-value care for defined patient groups. Current BC initiatives for clinical care management focus on guideline implementation and more consistent use of evidence based practices for specific patient safety and quality concerns. Population focused CCM systems would extend current population based initiatives, incorporating clinical microsystem design, knowledge management and organizational learning, physician engagement
  • and leadership, and be more broadly focused on designing effective care across the continuum.
  • Creating more effective CCM systems requires explicit efforts to organize clinical work in interdisciplinary teams with clearly defined aims, defined work processes and information flows, and well-organized patterns of work and learning that produce high-value care. These teams would require strong internal leadership as well as support from broader system resources to develop the necessary measurement, improvement and work design capabilities.
  • High-performing CCM systems would rely on the ability to implement high-performing CCM systems relies on a supportive organizational and policy context that addresses the availability of an effective information technology platform, well-aligned incentives, leadership capacity across the system, and resources and investments for capacity development.
  • Because of their focus on clinical care, CCM systems provide an effective approach for engaging physicians and others professionals in initiatives for organizational and health systems improvement. 
  • Given the growing importance and nature of chronic disease and the needs of complex “high-use” patients, the development of CCM systems must go beyond acute care settings and be deployed in primary care and community settings.
  • To develop high-performing CCM systems within regional authorities, a step-by-step approach is recommended. This approach focuses initially on identifying sites with the greatest potential to fully deploy CCM systems and where they would have significant impact on cost, quality and health improvement. To test the feasibility and value of extended CCM systems for the Fraser Health Authority, we propose the following steps:
    • Identify the population focus and core system elements for CCM system improvement.
    • Create a clinical care management guidance council to identify improvement objectives,
    • to provide advice and knowledge management support, and to involve key clinical leaders.
    • Examine current outcomes and patterns of care for selected populations in one or more
    • districts, benchmarked against other districts, regional authorities and relevant comparisons.
    • Identify effective care processes and high-value improvements for selected populations.
    • Test and implement changes in care processes in selected care settings to support better
    • clinical outcomes and improved patient experiences at the same or reduced costs.
    • Design and deploy a deliberate strategy for physician engagement and leadership.
    • Implement senior leadership oversight for the clinical care management system pilot.