Transcript Continuous care in chronic conditions

Continuous Care in Chronic
Conditions
Learning's from a project between Bispebjerg
Hospital and Copenhagen Community
“Improving Care in Europe and the US: Towards
patient-centered, proactive and coordinated systems of
care”
Anne Frølich, MD, Ass. Professor,
Department of Health Services Research, Bispebjerg
Hospital, University of Copenhagen
Project members
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Jens Egsgaard
Carsten Hendriksen
Dorte Høst
Helle Schnor
Cecilia Ravn Jensen
Goals for the project
1. Improve care in chronic conditions focusing on
continuity
2. Develop a model that support chronic care
Focus on Chronic conditions
Recommendations for Improvement of Care in
Chronic Conditions, National Board of Health, Year
2005
Prevalence rates of the most
common chronic conditions
COPD
200.000
4%
Type 2 DM 200.000
4%
CHF
200.000
4%
Muscle200.000
4%
Skeletal conditions
Osteoporosis 300.000 6%
National Board of Health – Publication with
Recommendations
Patient, Healthcare and Society
Reaching for a more Coordinated
Healthcare System
The Structure Reform:
• Reduced the 14 counties to 5 regions
• 278 Municipalities was reduced to 98
The new health act:
• Mandatory Healthcare Agreements to avoid
fragmentation:
• Focus on discharge from hospital for weak
elderly patients, agreements on social services
for people with mental disorders and
agreements on prevention and rehabilitation
The Local Government Reform
New Healthcare Act
One of the major changes following the new health
care act is transfer of the responsibility for
rehabilitation and health promotion services from
the regions to the municipalities
Coordination of Care
Macro level
State level, healthcare
agreements between regions
and municipalities
Meso level
Organizational level
Micro level
Patient-provider level
Methods and Material
Copenhagen Municipality: 503.000 citizens
Østerbro local area: 80.000 citizens
Bispebjerg Hospital: 700 beds and 3.500 employees
General practitioners: 57 GP’s, 50% in solo practices
Conditions:
COPD
Type 2 diabetes
Heart failure
Balance problems
New Organization at the Municipality Level:
Health Center
Rehabilitation in the hospital and at the
municipality level – health center
Activities in a rehabilitation unit:
• Primary assessment, physical tests and quality of
life tests
• Physical Training
• Smoking Cessation
• Patient Education
• Dietician Counselling
• Psychosocial support
• Planned follow-up
Coordination at the Organizational Level
• Coordinated leadership across sectors - horizontal and vertical
cultures and goals for patient care aligned to some extend
• Disease management programs developed across sectors
• Agreed stratification of patients between sectors ex. COPD FEV1% of
expected magnitude limit at 50% changed to 30%
• Use of identical measures including, diagnosis, diagnosis specific, general
measures (BMI, smoking rates, etc., ), physical measures (senior fitness tests), quality of life; general
and disease specific,
• Knowledge sharing meetings
• Teaching programs across sectors for nurses and therapists and for physicians
• Sharing of patient information – referrals, summary
• Follow-up
either in rehab. units or in local society,
Coordination at the Patient – Provider level
• Action plans - Agreements between patient and
provider for goals of the rehabilitation
• Patient education – activation of the patient
Barriers to Coordination
• Non-aligned financial incentives between
sectors
• Culture differences between sectors
• IT-systems not able to communicate sufficiently
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Model for Chronic Care
Coordinated Leadership across Sectors
Patient / citizen
Toolbox
Bispebjerg Hospital
Copenhagen Municipality
Leadership
Health professionals
Competences
Leadership
Coordination supported by:
Health professionals
•Clinical guidelines
Competences
•Agreed stratification of patients
•Identical quality assessment measures
•Knowledge sharing meetings
•Sharing of patient information
•Follow-up
Patient / citizen
General Practitioners
Leadership
Health professionals
Competences
Patient / citizen
Coordinated Leadership across Sectors
Thank you for your attention!
The Chronic Care Model
• Some of the best
practices in the chronic
care model:
From Improving Chronic Illness Care
Ed Wagner, MD, Group Health Cooperative of Puget Sound
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Leadership
Resources
Financial Incentives
Provider Feedback
Program Evaluation
Patient Action Plans
Patient Education
Guideline Training
Provider Alerts
Electronic health record
Defined Care Path
Risk Stratification
Registry
Follow-up
Inreach
Care Coordination
Team-Based Care
Cultural Competence
Population Management Levels of Care
Advanced Disease
Complex Co-morbid Conditions
Complex Psychosocial Issues
Frail Elderly
Need close surveillance of
symptoms, medication titration,
and intensive self-management
education:
• Not in control
•Adherence problems/
Depression
•Complex medication
regimen
•Co-morbid conditions
•Need Medications
•Under Control
•Lifestyle Changes
Specialty
Care
Assisted Care for
Multiple Risk Factor
Management Meds, Get to Goal,
Lifestyle Change
Primary Care with
Support Meds, Get to Goal,
Lifestyle Change
Level 3
1-5%
Specialty MD Care
Coordination with
case/care
management,
eCare
Level 2
20-30%
Nurse or
PharmD Care
Management
MA with MD
eCare
Level 1
65-80%
PCP Care,,
Pharmacist
eCare, Web
Results
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Number of patients dived by diagnoses:
COPD
Type 2 diabetes
Heart failure
Balance problems
COPD
• Se konklusionen..
Rehabilitation units in the hospital and
rehabilitation centres in the community
Patients at level 2 and some in 3 receive rehabilitation in
the medical centre and patients at level 3 in the
hospital
It is a demand that diagnoses and medical treatment are
in place when patients are referred to rehabilitation
Activities in a rehabilitation centre:
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Primary assessment, physical tests and quality of life tests
Physical Training
Smoking Cessation
Patient Education
Dietician Counselling
Psychosocial support
Planned follow-up
Model for improved continuous care
Tværsektoriel ledelse
Patient / borger
Tool box
Bispebjerg Hospital
Københavns kommune
Leadership
SCØ, andre kommunale aktører
Ledelse
Personale
Faglighed
Sammenhænge understøttes af:
Forløbsbeskrivelser
Stratificering
Monitorering
Videndelingsmøder
Informationsudveksling
Fastholdelse af effekt
Praktiserende læger
Ledelse
Personale
Faglighed
Patient / borger
Tværsektoriel ledelse
Health professionals
Competences
Patient / borger
Continuous care is supported by:
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Forløbsbeskrivelser
Stratificering
Monitorering
Videndelingsmøder
Informationsudveksling
Fastholdelse af effekt
SIKS modellen
Tværsektoriel ledelse
Patient / borger
Værktøjskasse
Bispebjerg Hospital
Københavns kommune
Ledelse
SCØ, andre kommunale aktører
Ledelse
Personale
Faglighed
Sammenhænge understøttes af:
Forløbsbeskrivelser
Stratificering
Monitorering
Videndelingsmøder
Informationsudveksling
Fastholdelse af effekt
Praktiserende læger
Ledelse
Personale
Faglighed
Patient / borger
Tværsektoriel ledelse
Personale
Faglighed
Patient / borger
The National Strategy for Health
Promotion and Prevention Focus on
Improvements in eight Chronic Conditions
Prevalence rates of the most common chronic
conditions
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Diabetes
COPD
Coronary Heart Disease
Osteoporosis
Muscle skeletal disorders
Asthma and allergy
Cancer
Psychiatric diseases
300.000
300.000
200.000
300.000
800.000
1.000.000
100.000
The National Strategy Focus on
Improvements in
Eight Chronic Conditions
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Diabetes type 2
COPD
Cardiovascular diseases
Osteoporosis
Muscular and skeletal disorders
Allergy
Mental diseases
Preventable malignancies
Background for the project
• High and rising prevalence rates of chronic
conditions
• The structural reform and the new health
act
New Covered Services in the Primary Care
Sector
• One-year follow-up in diabetes patients (type 1
and 2) including regularly controls, recording of
diagnosis to IT system, ensure patients undergo
recommended screenings
Experiences from DM will be used to develop
benefit models in other chronic conditions such a
COPD, asthma, CHF, depression etc.
Continued – New Covered Services in the
Primary Care Sector
• Prevention consultations related to life style
factors such as tobacco use, alcohol, Physical
activity nutrition, and Other risk factors and
integrated counselling
• Home visits to frail elderly once a year
• Screening for depression
Rehabilitation units in the hospital and
rehabilitation centres in the community
Patients are stratified to receive rehabilitation in the
hospital if the belong to level 3 and patients at level 1
and 2 in the health center
It is a demand that diagnoses and medical treatment are
in place when patients start rehabilitation
Activities in the rehabilitation centers:
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Primary assessment, physical tests and quality of life tests
Physical Training
Smoking Cessation
Patient Education
Dietician Counselling
Psychosocial support
Planned follow-up