Dr. Richard Lewanczuk Senior Medical Director Primary Care, Chronic Disease Management, Community and Rural Alberta Health Services

Transcription

1 Principles of Chronic Disease Management Dr. Richard Lewanczuk Senior Medical Director Primary Care, Chronic Disease Management, Community and Rural Alberta Health Services

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4 I am going to say nothing about addictions, but during this presentation see if you might imagine if any facets of a Chronic Disease Management approach might apply to addictions. Which ones might not apply?

5 obesity fat cells and fatter fat cells IL-6 TNFα CRP inflammation adiponectin resistin leptin ang II other hormonal changes insulin resistance dysglycemia AGE s, activation of RAGE glycemia receptor activation shunting of glucose to FFA, triglyceride synthesis inhibition of insulin secretion, β-cell apoptosis

6 stress cortisol, GH, testosterone, DHEA-S obesity fat cells and fatter fat cells adiponectin resistin leptin ang II other hormonal changes IL-6 TNFα CRP insulin resistance dysglycemia inflammation shunting of glucose to FFA, triglyceride synthesis AGE s, activation of RAGE glycemia receptor activation

7 Commonest cause for hospitalization in Alberta : 1. Mental health 2. Exacerbation of chronic lung disease 3. Exacerbation of heart failure

8 % increase in Medicare costs stroke hyperlipidemia lung conditions diabetes cancer arthritis mental illness heart disease hypertension % increase in cost Thorpe and Howard, Health Affairs 25:w378, 2006

9 Chronic disease prevalence in the adult population - Edmonton heart disease diabetes asthma depression skin hearing hypertension vision arthritis back %

10 Number of comorbidities in the general adult population - Edmonton > %

11 Prevalence of 2 or more chronic diseases Edmonton (all ages) Daveluy Fortin % prevalence 1) Alberta Health Services 2) Daveluy et al, Institute de la statistique du Quebec, ) Fortin et al, Ann Fam Med 3:223, 2005

12 Why are chronic diseases so common? All of us will have hypertension by age 83 ½ of us are overweight or obese 1/3 of us have high cholesterol ¼ of us will develop diabetes Most women will have osteoporosis by age 73 1/5 women and 1/10 men will develop Alzheimer s ¼ of us will have a significant mental illness at some point in our lives 1/5 women and 1/6 men will have a stroke; 1/3 of us will be disabled by a neurological disease

13 Time to first hospitalization in COPD patients with co-morbid disease

14 Relative health care spending in California based on number of chronic conditions 20 $18.60 relative $ per pat $12.11 $9.90 $5.29 $3.30 $ number of chronic conditions adapted by R Lewanczuk from GF Anderson Johns Hopkins Bloomberg School of Public Health. Analysis of Medical Expenditure Panel Survey (MEPS) data, 2002.

15 Cost of Care - Alberta cost per patie $ $ $1, $10, $4, healthy acute major chronic 3 major chronic cancer Alberta Health Services 2010

16 Reactive, episodic illness care is no longer tenable We can t keep doing the same thing and expecting different outcomes

17 What is the goal of Chronic Disease Management? to keep people healthier, longer

18 Life expectancy at birth 80 life expectancy Men disabled years disability-free years life expectancy Women disabled years disability-free years

19 Principles of Chronic Disease Management responsible for an entire population group identify patients (case finding, screening) stratify by risk and provide care in least intensive setting treatment in the community before it impacts on more complex acute care services primary care provider runs the show - provides care, coordinates care, is responsible

20 Principles of Chronic Disease Management involve patients in their own care (goal setting) interprofessional teams patient support in disease management with education and ongoing followup the system supports the family physician patient relationship (infrastructure, financial, training, linkages to other parts of the health care system, etcetera) the system supports specialty and other services to, in turn, support primary care

21 Principles of Chronic Disease Management specialists act as advisors, mentors, resource information systems allow access and transfer of key patient data in a timely manner integration of care across organizational boundaries performance measurement tools help guide care

22 CDM Levels of Care Primary Care Physicians Teams and PCNs are supported to provide the best care to the most people Specialty clinics provide care management to complex cases Case management is reserved for the most challenging situations 100% case management 80% care management 60% usual care with support 40% 20% 0%

23 Chronic Disease Model

24 The Chronic Care Model Community Resources and Policies Linkages to community-based resources/ partners Policies to promote/ prevention of CDM Health Care Organization Leadership, culture and mechanism to promote safe, high quality care. Effective relationships with other stakeholders Clear structures and goals

25 Steps in CDM 1. Screen / identify patients with condition (gold standard Dx) 2. Register patients with condition 3. Determine responsibilities within the team; role of specialty and Regional programs 4. Develop or implement care maps, protocols (decision support; evidencebased) 5. Ensure patients are on care maps and develop means to track patients, mechanisms for alerts and updates to patient plan 6. measure/evaluate system,disease specific, intermediate endpoint, hard endpoint 7. Allow for patient self-management 8. Consider whether community resources may be utilized

26 Strategies to prevent chronic disease know your panel IT/IS supports for reminders, flags, etc. effective individual preventative measures: risk identification clinic level skills (motivational interviewing, barrier identification) other supports: psychology, social work System support: community resources, policy, etc.

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28 % of day required for CDM based on published guidelines 140 % of day perfect control real-life, top 5 real-life, top Lewanczuk, adapted from Ostbye et al Ann Fam Med 2005; 3:209 based on average family physician work day

29 Factors contributing to clinical inertia - clinician failure to initiate treatment failure to titrate to goal failure to set goal underestimation of patient need failure to recognize and manage co-morbidity insufficient time insufficient focus or emphasis on goals reactive care

30 Factors contributing to clinical inertia - patient side effects too many medications forgetfulness cost denial of disease denial of severity perception of low risk absence of symptoms mistrust of clinician poor communication low health literacy psychological, substance abuse lifestyle

31 Factors contributing to clinical inertia - system no clinical guidance no disease registry no visit planning no proactive care no decision support no team approach or coordination poor communication between members

32 motivational interviewing healthy living programs goal setting adherence Be your own boss Stanford spiritual mental health screening social Flinders patient-reported outcomes

33 Treatment Adherence

34 Patient-identified barriers to diabetes control % psychological (priorities, motivation, self-efficacy, competing demands, emotional) % external physical (access time, appointments, mobility, location; monetary) % psychosocial internal physical (other conditions, side-effects) % educational

35 Determinants of treatment adherence demographics biological markers health history time with condition symptoms (or lack of) acceptance of condition perceived benefit perceived risk co-morbidities complexity of regimen stage of change physician-patient relationship pharmacist-patient relationship prior treatments/attempts expectations/beliefs habits social factors psychological state goals triggers social support side effects cost refill convenience lifestyle disruption motivation self-confidence knowledge

36 Barriers to self-management number of diseases depression physical functioning self-efficacy health literacy disease burden compound effects of multiple conditions overwhelmed by one condition financial constraints social activity Bayliss et al, Ann Fam Med 5:395, 2007

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39 An older psychotropic drug: improves memory and cognitive function enhances mood improves fatigue improves depression decreases anxiety, calming not associated with weight gain; prevents weight gain

40 The real history of evidence-based medicine Sackett, evidence based medicine, BMJ 312:71, 1996

41 10 ways to improve compliance: 1. address stress, depression and coping skills 2. tailor advice to a person s life and routine 3. understand perceived barriers 4. strengthen healthcare provider-patient relationship 5. be empathetic, non-judgmental, positive, supportive. NEGATIVE and THREATS do not work!!!! 6. promote ownership of their condition and self-management 7. improve confidence and self-efficacy 8. move people towards intrinsic motivation 9. focus on what is important to patients (i.e. QOL) 10. understand each person as a unique individual

42 Chronic Disease Management - What does this mean for the patient? Health Care not Illness Care Personal responsibility Strong emphasis on staying healthy with support to do this! The health care team works with the patient to be proactive in maintaining health (e.g. assesses risk for conditions, keeps up to date with routine interventions such as immunization, Pap smears, blood pressure checks)

43 What does this mean for the patient (cont d)? Increased community supports Increased access to information (e.g. patient portal) Care coordinated and managed by primary care team Less reliance on just physicians, increased access to other health care professionals Specialists see more complicated patients Ability to access appropriate care, at right place, right time (i.e. shorter waiting lists or no waiting lists) All health care needs are addressed, not just a single problem

44 What does this mean for the patient (cont d)? Did we make a difference? Does the patient feel better? Does the patient function better?

45 Patient-reported outcomes

46 Why Patient Reported Outcomes? Patients want to feel well Patients want to function better Functional status is linked to health status Functional status is predictive of resource utilization Mental health status determines behavior change, compliance PRO s help identify what is important to the patient

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48 Conditions with greatest impact on: physical health: arthritis incontinence back problems COPD liver problems diabetes heart disease asthma mental health: depression eating disorder incontinence hearing loss skin problems back problems obesity

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50 Strategic Priority: Screening Effective screening for chronic disease risk at the level of the individual in primary care Activities: 1. With stakeholders, identify screening priorities 2. Provincial Screening Advisory Committee ensure screening programs are evidence based & costeffective, and there is system capacity to manage positive results, relevant to Alberta context 3. Develop tools to integrate screening programs

51 Strategic Priority: Diverse & Vulnerable Populations Diverse & vulnerable populations throughout the province have access to customized and culturally appropriate primary care and CDM services Activities: 1.Map out diverse populations & targeted programs; match need to service 2.Seek opportunities to develop capacity in PCNs and community 3.Utilize a partnership model with community organizations 4.Raise awareness and develop skills in PC providers

52 Strategic Priority: Self-Management Improved self-efficacy, symptom management, and clinical and patient-reported outcomes in patients with chronic disease (enable self-management) Activities: 1. Develop tools, resources and provider education to enable a selfmanagement and shared-decision making approach 2. Develop evaluation framework to assess the effectiveness of selfmanagement programs and supports 3. Explore/develop models and tools for self-management for youth population 4. Develop tools to identify those with the poorest self-management skills. 5. Collaborate with AHW to develop a personal health portal

53 Strategic Priority: Community-based Services Community based services to support chronic disease management are available and reflect care of the whole person Activities: Complete a provincial inventory of community programs, especially in rural communities Partner with communities to develop alternative service delivery models, emphasis on integrated approaches

54 Strategic Priority: Community & Patient Engagement The integration of community and patient priorities into service planning and care delivery Activities: Community and patient representation on service planning teams Establish feedback mechanisms Develop tools and resources that foster patient- and familycentered care

55 Strategic Priority: Registries Capacity provincially, within zones, and primary care, to identify patients with chronic diseases and enable feedback on guideline application in practice through use of provincial registries Activities: Chronic Disease Registry Working group Collaborate with POSP and IT to develop infrastructure to integrate registries for multiple diseases Build linkages between surveillance systems

56 Strategic Priority: Team-based Care Albertans have access to physician-led and inter-professional based primary care in which teams of providers are working to full scope Activities: 1. Develop role descriptions adaptable to range of practice settings 2. Develop tools to facilitate role optimization and collaborative practice 3. Establish linkages with academic faculty/educators to inform curriculum planning

57 Strategic Priority: Primary-Specialty Care Transitions Smooth transitions between primary and specialty care in the appropriate practice setting, and by the appropriate provider Activities: 1.Complete best-practice review of wait-time reduction initiatives 2.Develop standardized referral criteria to specialty care 3.Develop tools and processes for transitioning patients back to primary care 4.Determine tools and supports PC requires to manage CD patients 5.Develop and implement a case-management model to improve access and coordination

58 Strategic Priority: Research A research and evaluation framework for primary care and chronic disease management that informs strategy development and guides related practice Activities: 1.Collaboratively develop QI, performance measurement, evaluation and research tools 2.Collaborate to develop primary care and CDM research questions, proposals, and dissemination strategies 3.Regularly review key health system drivers and how to integrate these into CDM planning

59 Strategic Priority: Integration Integrated programs and services for patients with chronic disease that reduce duplication and costs to the system and the individual Activities: 1. Identify chronic conditions that would benefit from common interventions and integrated services 2. Develop innovative models that integrate services, are patientcentric, and ensure care in the most appropriate setting 3. Establish integrated pathways of care

60 Strategic Priority: Provider Education Responsive and sustainable inter-professional education programs that enable providers to engage in evidence-based approaches to chronic disease management Activities: 1. Provincial inventory of provider education programs identify gaps 2. Professional Education Working Group 3. Recommend infrastructure that supports equitable access to education programs and is sustainable 4. Develop a framework to evaluate education programs

61 Discussion/Questions?