Complex Chronic Disease Patientsbetter results at a better cost
Gerry Bédard, MDAlain Larouche, MDGuylaine Chabot, M.P.A.June 2012
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PRESENTATION PLAN
1. The number one issue: complex chronic diseases2. The Concerto health model3. The showcase4. An outstanding living laboratory5. The implementation process
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THE NUMBER ONE ISSUE
Complex chronic disease (CCD) Complex chronic disease: several CDs affecting one patient The accumulation of CDs: 25% of the population has two or
more CDs A pathological problem in itself: the diseases have a
harmful synergistic effect on each other Uncoordinated care: a harmful effect on complex CDs Prevention: acting on health behaviours
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% of people hospitalized according to condition
People with 3 or more chronic diseases account for 71% of all admissions.
NOTE
Number of chronic diseases
0 1 2 3 4 5+0%
10%
20%
30%
40%
50%
60%
52%
24%
11%
7%4% 3%4%
7%
12%
17%
23%
31%
% of population with or without chronic diseases total % of hospitalizations
Impact of chronic diseases on the health system
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Ratio population/expenditures according to condition
People with 5 chronic diseases or more (3% of the population) account for the same expenditures as people with no chronic diseases (52% of the population).
NOTE
Ratio
pop
ulati
on/e
xpen
ditu
res
Source: Medical Expenditure Panel Survey2001
Number of chronic diseases
0 1 2 3 4 5+0
2
4
6
8
10
12
14
16
18
1.00
2.68
5.01
6.99
9.18
16.31
Impact of chronic diseases on the health system
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3% of the population • 50% of inpatient days
Data validated for the entire Québec population
5,000 FTE nurses required for this care
Impact of chronic diseases on the health system
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THE CONCERTO HEALTH MODEL
Description Optimal, front-line care management of a population
registered with a family medicine group (FMG) Complete interdisciplinary team: physicians, clinical nurses,
other professionals Services adapted to patient categorization Care and service pathways Proven information system
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Approach
Population health• Services offered close to the patient’s home• Holistic approach• Health prevention and promotion• Screening for chronic diseases
Priority given to chronic diseases• Categorization• Multimorbidity: complex chronic patient• Collaborative approach: interdisciplinary team with the
patient
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4Complex
cases3
Patients with highrisk of complications
2Chronic diseases
1Healthy population
Chronic disease management pyramid• From the “Chronic
Care Model” by Ed Wagner et al.
• Improved (Canadian version)
The cornerstone of the model
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19 target diagnoses and conditions
Diabetes High blood pressure (HBP) Dyslipidemia COPD Asthma Chronic heart failure (CHF) Arteriosclerosis disease Chronic renal failure (CRF)
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19 target diagnoses and conditions Mental health• Depression• Anxiety disorders• Attention deficit hyperactivity disorder (ADHD)
Oncology and palliative care• Chronic pain
Dementia and loss of autonomy Neonatal follow-up Pregnancy follow-up Regular medical exam• Screening• Prevention and promotion
Roles of health professionals
FMG• Offer access to continuous, quality services
Interdisciplinary team• Personalize the services offered• Optimize the family physician/clinical nurse duo
(ongoing collaboration)• Foster the expertise potential of each professional
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Roles of health professionals
Clinical nurse (university degree)• Provide personalized patient follow-up• Offer relevant instruction• Promote self-care• Coordinate care (key role)• Ensure smooth case management for complex patients
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Roles of health professionals
Physician• Diagnose clinical conditions• Prescribe the care trajectories
– Make sure of patient’s follow-up• Support the nurses and other professionals• Provide the periodic medical follow-up required
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Roles of health professionals
Other professionals• Support the nurses according to the care trajectory• Participate actively in the care of patients at high risk of
complications and with complex cases• Coordinate care and services with the other CSSS
professionals– Front-line care– Specialized care
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Roles of health professionals
Health and social services centre (CSSS)• Relocate health care professionals to FMGs• Validate collective prescriptions (director of nursing)• Coordinate activities in the region• Provide and coordinate access to services
– Home care– Specialized clinics– Medical specialists– Technical support
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Roles of health professionals Concerto health group• Develop care and service pathways• Produce collective prescriptions• Categorize patients• Identify frequent users• Coordinate professional training• Support health care professionals in managing change
– Organization of work– Professional practices– Adoption of computerized solutions
• Evaluate and improve administrative processes on an ongoing basis
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Tools Care and service pathways based on consensus and
relevant data• Screening• Clinical assessment• Teaching• Lab tests• Decision support• Treatments• Interprofessional references• Follow-up according to clinical condition
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Tools
Technology platform• Interprofessional intervention tool• Exchange of information with patients
– Patient portal– Telehomecare (telemonitoring and remote follow-up)
• Database– Manage population data– Manage clinical processes– Manage results
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Tools
Decision support Collective prescriptions: sharing of reserved medical
activities• Lab tests• Therapy adjustments
Report to physician
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Training program for all professionals
Motivational approach• Éducoeur-en-route• Health coach
Collaborative approach: the real interdisciplinary work including the patient
Case management Specifics and complications per pathology Post-training support
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Dynamic assessment
Dashboard• Clinical process tracking indicators
– Accessibility– Continuity– Appropriateness– Productivity– Care quality– Satisfaction– Societal costs
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Dynamic assessment
Dashboard• Outcome indicators
– Behavioural changes– Empowerment– Improved state of health– Level of use of services
Emergency room stretchers Hospital beds Beds in long-term care centres (CHSLD)
IIIP + case management
IIIP*
Care
traje
ctorie
sPr
even
tive
scre
enin
g
4Complexcase
s3Patients with high
risk of complications
2Chronic diseases
1Healthy population
Population
Categorization
Strategic clinical alliance
CSSS
Family physiciansFront line
Relocation of interdisciplinary team
• Care pathways• Protocols • Collective
prescriptions• Teaching
*IIIP: Individualized interdisciplinary intervention plan
Personalization of care
(multipathologies + comorbidities)
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Chronic disease management
system
Population health management
Coordination of care and services –
THE CHALLENGE
Telehomecare - telemonitoring
Health portal
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Interdisciplinary training
Optimal medication management
TeachingLifestyle habits
(Éducœur-en-route)
Measuring societal costsProactiveness
Productiveinteraction
Measuring satisfaction and quality of life
Well-trained, proactive staff Well-informed patients
and loved ones who are partners in care giving
THE SHOWCASE
Degree of progress 17 months of activities 2 FMGs in Sud de Lanaudière Collaboration agreements• Ministry of Health and Social Services• Regional Health Board of Lanaudière• Sud de Lanaudière Health Center (CSSSSL)• Concerto Health Group
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Interdisciplinary team
Family physicians (20) Nurses (10 FTE) Pharmacist (0.8 FTE) Nutritionist (0.8 FTE) Respiratory therapist (1.0 FTE) Social workers (2 FTE) Psychologist (0.8 FTE) Physiotherapist (0.4 FTE) Occupational therapist (0.4 FTE)
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HPB/Dysl
ipemia
Dyslipem
ia only
HBP only
Diabete
s/HBP/D
yslipem
ia
Diabete
s/Dysl
ipemia
Diabete
s/HBP
Diabete
s only
2+ CDs
0
200
400
600
800
1000
1200
0%
10%
20%
30%
40%
50%
60%
70%
80%
14367
216
547
172 177 199
1039
9% 4% 14%
36%
11% 12% 13%
68%
Patient distribution according to diagnoses or groups of diagnoses among 2065 patients registered* on May 11, 2012
Number %
Patients with 3 diagnoses make up the largest group
Among patients with at least one of the
diagnoses, 68% have 2 or more diagnoses
* including 544 patients investigated or monitored mainly for respiratory problems (not shown on the chart)
Degree of progress
243 frequent users identified• 3 hospitalizations or more in 3 years• 5 events or more in 3 years
Interdisciplinary intervention plans• 65 completed in June 2012
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Results: trends
Satisfaction among nurses with regard to training• High rate: > 80%
Continuity of care• 3 visits or more plus
monitoring by the same nurse: 95.7% of patients
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Data gathered from October 2010 to February 2012 and produced on April 10, 2012.
Table showing the change in patients’ state of health based on HbA1c analysis results (1st period 0 – 6 months)
·21.95% of patients improved their result.·28.3% of patients maintained their result at the target level.·37.9% of patients remained stable, but not at the target level.·11.8% of patients saw their state of health deteriorate.
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2012 2013 2014
0 $
20,000 $
40,000 $
60,000 $
80,000 $
100,000 $
120,000 $
140,000 $
160,000 $
Changes from 2012-2014 in the cost of care professionalsversus CSSSSL and network efficiency gains
Clinical Team Costs $ Efficiency Gains $ (hospital only) Efficiency Gains $ (network)
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Results: trends
CSSSSL efficiency gains: costs recovered after a little more than 3 years of operation
Overall efficiency gains (CSSSSL and network): costs recovered after 2 years of operation
In the longer term: reduction in the expenditure growth curve
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Legal framework
Patient consent Confidentiality rules governing personal information Rules governing information access, retention and
circulation Rules for processing redacted information
Integrated Clinical Solutions
CHRONICDISEASE
MANAGEMENT
REMOTEPATIENT
MONITORING
PERSONALHEALTH
RECORDS
CHRONICDISEASE
MANAGEMENTSOLUTION
Technology Partner
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Pharmaceutical partners
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SanofiAstra-ZenecaBristol-Myers-SquibbPfizerShire
• Interdisciplinary training program
• Societal costs• Optimal medication
management
Collaborators Institut de recherches cliniques de Montréal• Éducoeur-en-route
Claude Sicotte, PhD: full professor, Faculty of Medicine, Université de Montréal• Dashboard
Fernand Couillard, MD, psychiatrist• Mental health care pathways
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OUTSTANDING LABORATORY: Living Lab
Better informed and monitored patients: “chronically
well” Innovative, advanced clinical practices for nurses Physicians better supported in their practice Demonstrated efficiency of the front line in response
to the health needs of the population Added value for the network’s performance Cutting-edge contribution for the evolution of health
care systems