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CHRONIC DISEASE MANAGEMENT Case Study Calgary/Canada, 2002-2009
Belo Horizonte November 11 -12, 2014
Where is Calgary ?
Rocky Mountains
Hockey
Chronic Illness
• “ Surveys across a variety of diseases including high blood pressure, diabetes, coronary artery disease, asthma and congestive heart failure have shown that 40 to 80 percent of patients are inadequately treated.”
Deficiencies include
• Rushed providers not following established practice guidelines
• Lack of care coordination • Lack of active follow-up to ensure the best
outcomes • Patients inadequately trained to manage their
illnesses
The System Needs to Change
• Our health system is designed to manage acute illnesses, not manage (much less prevent) chronic ones
• …and each system is perfectly designed to get the results it achieves
W. Edwards Deming, US Management Consultant, 1900-1993
World Health Organization
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Chronic Care in Calgary
To better address the problem of chronic disease, Calgary:
Formally began a Chronic Disease Program in 2002
Appointed a 1.0 Director and .5 Medical Lead
Targeted diabetes and hypertension
Provided project dollars
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Chronic disease management can’t be an add-on to someone’s current job
Key to Success
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Underlying Principles
Focus on secondary prevention
Use a ‘proven’ model of Chronic Care
Focus on building infrastructure rather than management of individual diseases
Be patient-centered and community-based
Work within existing operations
Be flexible with implementation
14
Key to Success
At developmental stage need people who can think outside the box
Guiding Framework – Chronic Care Model
• Developed in mid 1990s at MacColl Center for Health Care Innovation (Seattle)
Has been applied to a variety of chronic illnesses, health care settings and target populations
Shown to improve patient outcomes and reduce costs for many chronic conditions
www.improvingchroniccare.org
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Chronic Care Model
Productive Interactions
Prepared, Proactive
Practice Team
Improved Outcomes
Delivery System Design
Decision Support
Clinical Information
System
Self- Management
Support Resources &
Policies
COMMUNITY Health Care Organizations
Informed, Empowered
Patient
HEALTH SYSTEM
Health System
Create a culture, organization and mechanisms that promote safe, high quality chronic care – All levels of the organization need to visibly
support efforts to improve chronic illness care, – Develop agreements that facilitate care
coordination within and across organizations
Delivery System Design
Assure the delivery of effective, efficient clinical care and self-management support – Define roles and distribute tasks among team – Use planned interactions to support care – Provide case management for complex patients – Ensure regular follow-up by the care team – Give care that patients understand and fits with
their cultural background
Decision Support
Promote clinical care that is consistent with scientific evidence – Embed evidence-based guidelines into daily
clinical practice – Use proven provider education methods – Integrate specialist expertise and primary care
Clinical Information Systems
Organize patient data to facilitate efficient and effective care – Provide timely reminders for providers and
patients – Identify relevant subpopulations for proactive care – Facilitate individual care planning – Share information among providers to coordinate
care
Self-Management Support
Empower patients to manage their health and health care – Emphasize the patient’s central role in managing
their health – Use effective self-management support strategies
that include goal-setting, action planning and problem-solving
The Community
Mobilize community resources to meet needs of patients – Encourage patients to participate in effective
community programs – Form partnerships with community organizations
to support and develop interventions that fill gaps in needed services
Key System Challenges facing Calgary
Variation in care
Lack of care coordination and follow up
Limited use of multidisciplinary team
Patients inadequately trained to manage own illnesses
Financial incentives did not support good chronic illness care
Developed Care Algorithms
–Specified the care that was to be provided, by which provider, when and where
Developed for the key chronic conditions
All providers were involved
Led by medical specialists
Identified gaps in provider education
Assigned Multidisciplinary Teams to Support Family Physicians
–Some team members co-located in doctor’s offices to follow up patients (eg nurses)
–Others work in community settings to deliver patient education and provide supervised exercise programs (eg kinesiologists, physiotherapists, dietitians)
–Medical specialists provide in-services and support for complex patients
Living Well Community Program
• Living Well program provides:
Supervised exercise classes
Disease-specific education
Self-management classes
Aim of Program
Be accessible. Offered in community settings, e.g., gyms and community centres
Provide ‘one stop shopping’ for participants
Be sustainable – link with community organizations to expand reach
Be appropriate for people with a range of chronic conditions
Living Well Program
• Agreements with other organizations to provide disease education classes at sites
• Patients feel safe exercising as health professionals run class
• Program provide social support to patients
Introduced Self-Management Training for Patients
–Adopted the Stanford Chronic Disease Self-Management Program
Developed by Dr Kate Lorig in the 1980s at Stanford University (patienteducation.stanford.edu)
6 week program suitable for anyone with a chronic condition
Taught in small groups, by lay people
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Characteristics of Program
• Standardized training for leaders • Highly structured teaching protocol • Standardized participant materials • Sesame Street approach
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Core Assumptions
•Patients with different chronic diseases have similar self-management problems and disease-related tasks
•Patients can learn to take responsibility for the day-to-day management of their disease(s)
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Core Assumptions
• Trained lay persons with chronic conditions can effectively deliver a structured patient management/ education program
• Patient self-management education
should be inexpensive and widely available
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Patients spend less than .1% of their time in the physician’s office
Time spent in doctor's office (0.07%) vs. Time in self-management (99.93%)
(based on total of six hours per year)
Self-ManagementDoctor Visits
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35
36
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Introduced Care Plans
•A way for providers and patients to work together to manage a patient’s chronic conditions • Care plans outline the patient’s goals, upcoming interventions
and the role of all the providers involved in the care
•Why is care planning important? • Takes focus away from disease to patient as a whole • Facilitates communication between patient and providers • Is motivational for patients • Integrates medical and self-management
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Evidence for Care Plans •Better clinical outcomes
•Improved quality of life
•Reduced hospital admissions, unplanned GP visits, emergency visits
•Increased satisfaction with service
•More efficient clinical practice http://som.flinders.edu.au/FUSA/CCTU/contact.htm
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New Fee Code in Alberta for Family Physicians • 03.04J Complex Care Plan – the development,
documentation and administration of a comprehensive annual care plan for a patient with complex needs…$206.70 (Launched April 1, 2009)
•Patients must have at a minimum, either: • 2 from A; or • 1 from A and 1 from B
Column A •Hypertensive Disease (ICD-401) •Diabetes Mellitus (ICD-250) •COPD (ICD-496) •Asthma (ICD-493) •Heart Failure (ICD-428) •Ischaemic Heart Disease (ICD-413-414)
Column B •Mental Health Issues (ICD-290-319) •Obesity (ICD-278) •Addictions (ICD-303-304) •Tobacco (ICD-305.1)
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New Fee Code Launched April 1, 2009
Source: Calgary Herald, March 16, 2009
Monitor progress
Results
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Results – ACIC (Assessment of Chronic Illness Care)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
Mea
n Ra
ting
(0-1
1)
Literature (N=90) 2003 (N=27) 2007 (N=41)
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Results – HbA1c Control
0%
10%
20%
30%
40%
50%
60%
70%
80%
% <
= 7
%
Baseline 12 – Months
All (N=5492) Population
17% more patients with diabetes had blood sugar under control, p < .001
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Results – Hypertension
10% reduction in blood pressure among those at higher risk, p < .001
100%
110%
120%
130%
140%
150%
160%
180%
Mea
n Sy
stol
ic B
P
Baseline 6 – Months
All (N=464)
170%
High Risk (N=115)
134 131
160
145
High risk = > 145 at baseline
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200
400
600
800
1000
0
300
500
700
900
Visi
ts P
er 1
000
Patie
nts
Baseline 12 – Months
All (N=17233) Population
Results – ED Visits ED visits dropped by 34%, p < .001
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Inpatient Admissions dropped by 41%, p < .001
50
150
250
350
450
0
100
200
300
400
500
Visi
ts P
er 1
000
Patie
nts
Baseline 12 – Months
All (N=17233) Population
Results – Inpatient Admissions
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Bed days dropped by 31%, p < .001
Visi
ts P
er 1
000
Patie
nts
Baseline 12 – Months
All (N=17233) Population
0
1000
2000
3000
4000
6000
5000
Results – Bed Days
Key to Success
• Paradigm shifts take time
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Stay below the radar while testing different approaches and ideas
Key to Success
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At the Closing Bell…
‘ Progress is impossible without change and those who cannot change their minds cannot change anything ‘
George Bernard Shaw