Practice management in co-morbid patients
Jaime Correia de Sousa, MD, MPH
Horizonte Family Health UnitMatosinhos Health Centre - Portugal
Health Sciences School (ECS) University of Minho, Braga - Portugal
Objective
At the end of this session the participants will: Know why we need a new model of care for
co-morbid problems Value primary health care orientation in the
care for chronic patients Demonstrate the importance of clinical
information systems in the management of co-morbidity
Recognise the need for a chronic care model Value an approach to teaching and learning
about co-morbidity management
Introduction
Most patients with chronic illnesses do not have a single, predominant condition.
Most have co-morbidity, the simultaneous presence of multiple chronic conditions.
Patients seek care for all of their co-morbidities, not just for a solitary, defining, major condition.
Grumbach, 2003
Introduction
The majority of visits for care of both an indicator condition and its associated co-morbidities are made to primary care physicians.
What is needed is a model of care that addresses the whole person and integrates care for the person’s entire constellation of co-morbidities.
Grumbach, 2003
Case Study
• Mrs B, head teacher of a primary school, 52 years old, overweight, has diabetes mellitus
• Doesn’t exercise; easily tired with small efforts; has a bad knee that keeps bothering her. The cholesterol level is high.
• Mrs B blood pressure is regularly checked and is within normal values.
• Mrs B has smoked all her adult life
Case Study
• Mrs B came to see her FP with a bad attack of bronchitis and was told by her doctor that she suspected she had asthma.
• The doctor prescribed an AB for the bronchitis and an inhaler for the asthma.
• Mrs B disagreed with her diagnosis of asthma and so took the antibiotics only.
• Within about 2 weeks she was much better and felt vindicated in her opinion about the asthma.
Case Study
• She continued to have difficulty climbing the stairs to the third floor at the top of the school but she put her difficulty down to the ravages of age, overweight and cigarettes.
• Her peak flow when measured by the doctor in the surgery was 240 litres per minute. It should have been 480 litres per minute.
Case Study
In 5 m discuss in pairs:
1. Identify the major co-morbid health problems in this patient
2. The impact of a new diagnostic label and models of illness
Case Study
To discuss later in the group:• The most important tasks
required to promote a better care for this patient
• Design a care package for this patient, considering the aims of care and the resources needed
A new model of care?
Basic Questions Who should be involved
in care? What are our aims? How should we
organise care?
Basic Questions
What is the prevalence of co-morbidity among patients in family medicine?
How does this prevalence differ by the sex and age of the patient?
How does the prevalence differ between different conditions, particularly acute and chronic conditions?
Who should be involved in care?
PatientPatient
Patient’s familyPatient’s family
PHC TeamPHC TeamFamily physicians
Nurses Receptionists
HospitalHospital doctors and
nurses
CommunityCommunityPharmacists
PhysiotherapistsPsychologists Social workers
etc
What are our aims?
Provide the best available care Consider patient’s choices Realistic aims with available logistics (staff,
premises, funding) Adequate management of the health systems’
resources Prevention of health inequities Reduce the economic burden of illness in the
family
How should we organize care?
Traditional Chronic Disease Specific Approach
Chronic Care Model
Components of the Chronic Care Model
Community Organisation of health care Support self management Design of delivery system Decision support Clinical information systems
Lewis & Dixon, 2004
Components of the Chronic Care Model
Community Mobilise community resources to meet
needs of patients
Organisation of health care Create a culture, organisation, and
mechanisms that promote safe, high quality care
Lewis & Dixon, 2004
Components of the Chronic Care Model
Support self management Empower and prepare patients to
manage their health and health care
Design of delivery system Assure the delivery of effective,
efficient clinical care and self management support
Lewis & Dixon, 2004
Components of the Chronic Care Model
Decision support Promote clinical care that is consistent
with scientific evidence and patient preferences
Clinical information systems Organise patient and population data to
facilitate efficient and effective care
Lewis & Dixon, 2004
Primary health care orientation
Reconciling the health needs of individual patients and the health needs of the community
Community or list based, personally and family oriented
Health promotion, prevention, cure, care and palliation and rehabilitation.
Covering the full range of health conditions Co-ordination of care with other professionals Pro-active
Patient centred model
1. Exploring both the disease and the illness experience
2. Understanding the whole person 3. Finding common ground regarding
management4. Incorporating prevention and health
promotion5. Enhancing the Doctor-Patient relationship6. Being realistic
Levenstein (1984)
Patient centred model
The importance of clinical information systems
Appointments systems Enabling call and recall programmes Repeat prescribing Drug alerts (interactions, contraindications,
secondary effects) Decision support / expert-system Supporting audit
Model of care for patients with co-morbid conditions
Chronic care model
Patient centred modelPrimary health
care orientation
Clinical Information
System
Model of care for patients with co-morbid conditions
Chronic care model
Primary health care orientation
Patient centred model
Clinical Information
System
THE TRANSFORMATION
Care is Proactive
Care delivered by a health care team
Care integrated across time, place and conditions
Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology
Self-management support a responsibility and integral part of the delivery system
Chronic Care Model
Source: KPCMI
Complete Forms
Deal withAcute Attackof Disease
Counsel re: Lifestyle ChangesReview
LabsAccess
Social/Other Services
Reassure
Diagnose
General Referral
Review/Adjust Rx and Tx Routine
Preventive Care
Modify and/or Negotiate Care
Plans
Review History
Review Care Plan
Talk with Family
Reinforce Positive Health
Behaviours
Traditional Model
SICKNESS CARE MODEL (Current Approach - Physician Centric)
Consultation 10 minutes
So, how do we make this paradigm shift?
Start with better data extraction and information analysis to inform decisions
Implement case management for patients with highest burdens of disease
Implement guidelines for managing diseases and consider care co-ordination
Support self management and self care Measure progress and achievement; and
adjust process when necessary
Conclusions
1. Chronic illnesses are becoming the main activity of family physicians
2. Chronic diseases don’t exist isolated3. Frequently, patients have more than
one condition4. A generalist approach is necessary5. Shared care is important… but6. We need a family practice based
Chronic Care Model
Conclusion