Transcript Pacific Chronic Disease Council (PCDC)

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Council of National Association of Chronic
Disease Directors (NACDD)
Mr. John Robitscher, CEO
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Members are designated by
Directors/Secretaries/Ministers of Health
Board of Directors consists of (6) voting
members representing 6 jurisdictions of
USAPI.
Has 16 members: American Samoa (2)
Commonwealth of the Northern Mariana
Islands (2) Guam (2) Federated States of
Micronesia (5) Republic of the Marshall
Islands (3) and Republic of Palau (2)
Presented by: Augusta Rengiil, RN., BSN, MPH
PCDC/NACDD
In 2010, the Pacific Island Health Officers
Association in their 47th PIHOA meeting
declared a state of emergency due to the
epidemic of NCDs. The resolution encouraged
the collaborative work necessary to combat
the burden of NCDs in the region.
Since 2009, the Pacific Chronic Disease
Council, a council of the National Association
of Chronic Disease Directors (NACDD), has
provided leadership in the development of a
NCD collaborative model that proactively
targets health-care system change and
expansion of population outreach efforts.
The burden of non-communicable
disease (NCD) is increasing in the U.S.
Associated Pacific Islands. PCDC
report the results of a collaborative
model pilot, using local trainers, to
strengthen the quality of NCD
prevention and management in the
region. Lessons learned provide a
framework to help sustain
achievements and improve reach.
-This
PCDC report describes the
PCDC NCD collaborative pilot
approach, summarizes outcomes,
and outlines lessons learned that will
help sustain continued development.
-Funded by DOI thru CDC
The U.S. Associated Pacific Islands
(USAPI) jurisdictions (Figure 1) are facing
an increased burden of noncommunicable diseases (NCD),
particularly diabetes and cardiovascular
disease. Changing sociodemographic
factors, including population aging,
economic growth, and upward trends in
high-risk lifestyle behaviors (e.g.,
tobacco use, physical inactivity, and
unhealthy diets) are associated with the
increase in NCDs.
Combating NCDs requires
multisectoral partnerships to
implement policies that target
population-level risk factors and
ensure that essential, cost-effective
primary health-care services are
available to patients with NCDs.
Most health systems within the
USAPI have been positioned to
handle communicable disease
threats, acute illness, and
maternal-child health with NCDs
presenting new demands on
health-care systems.
As the burden of NCD increases
within the USAPI, transforming
healthcare systems (Changing
Practices), especially at the
primary level, to respond
efficiently and effectively to the
challenges of chronic disease
prevention and management
becomes a priority.
Although USAPI population health surveillance data are
limited, a recent review of USAPI mortality data
(between 2003 and 2010) showed that the top five
leading causes of death included at least two NCDrelated conditions (i.e., heart disease, hypertension,
renal disease, or diabetes). Additionally, the
prevalence of NCD within the USAPI, particularly
diabetes, is among the highest in the world. For
example, the estimated diabetes prevalence for
Pohnpei, FSM, was 32.1% (adults 25-64 yrs., fasting
blood glucose [FBG] ≥126 mg/dL) and for the RMI was
29.8% (adults 15- 64 yrs., FBG ≥110 mg/dL). In
comparison, the 2012 estimated prevalence of
diabetes for the U.S. population (adults ≥ 20 yrs.;
diagnosed and undiagnosed) was 9.3%
Based on the recommendations from the
assessment published (conducted by PCDC
under the leadership of Dr. Henry Ichiho)
and support from local health professionals’
familiar with the collaborative process and
CCM, in 2011 the PCDC began development
of the NCD collaborative pilot. The goal of
the pilot was to determine the feasibility of
adopting the CCM as a strategy to improve
the quality of NCD health outcomes within
the region.
In May 2012, NCD collaborative pilot teams
comprised of 3-5 members (e.g., physician, nurse,
data staff, and administrators) were established in
the 4 states of FSM and Majuro, RMI. The pilot
design, tailored after the HRSA Health Disparities
Collaborative, included three major components:
the CCM, learning process, and quality
improvement cycles. Additionally, the pilot relied
significantly on the skills and expertise of the
PCDC leadership and local health professional
trainers familiar with the use of health-care
collaborative and CCM within the region.
The CCM (Figure 2) served as the pilot’s implementation
framework and is comprised of six interrelated elements: 1)
community resources and policies, 2) health system
organization, 3) self-management support, 4) delivery
system design, 5) decision support, and 6) clinical
information systems. The CCM targets proactive,
population-based health-care through: self-management
support strengthened by more effective use of community
resources; enhanced health system organization and design
incorporating evidence-based disease management; and use
of patient registries and other information technology.
These elements synergistically serve to support and
demonstrate evidence-based systems changes to improve
health outcomes for both the individual and the population
within the system’s milieu.
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Informatio
n
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
The learning process included 4 interactive
learning sessions and action periods (across 18months) aimed to engage teams in applying the
CCM and using a cyclical and iterative quality
improvement process (plan, do, study, act) to
redesign their health-care systems. Each learning
session focused on training and coaching teams,
peer encouragement, data review, and problem
solving. The fourth learning session involved
documentation of progress and health outcomes
using storyboards to illustrate strategies and
commitment for continued planning of spread for
system change.
NCD Collaborative Measures
Using the CCM elements as a guiding framework (Table 1),
each pilot team created system level aims, identified core
and secondary measures (i.e. process or outcome), and
crafted change ideas targeting health-care improvements
within their primary health-care setting. Additionally, each
team randomly selected a population of focus of 50 patients
(adults, ≥ 18years) with diabetes (Majuro selected 100) to
provide a baseline for measuring clinical performance.
Clinical performance measures (core and secondary) were
chosen by pilot sites based on their review of current
American Diabetes Association (ADA) standards of medical
care in diabetes and the World
Health Organization’s recommended (PEN) Package of
Essential NCD interventions in low-resource settings.
Collaborative trainers also incorporated the USAPI Standards
for the Management of TB and Diabetes, established in 2010,
by multiple partners including PCDC and the Centers for
Disease Control and Prevention.
Each pilot site used the Chronic Disease Electronic
Management System (CDEMS), an open-source patient registry
and data management software application to track progress
related to clinical performance measures.
Teams were asked to submit monthly narrative and data
reports linked to measuring progress in the CCM system
improvement efforts.
Pilot Interventions and Evaluation
Table 2 presents examples shared by each team of improvement
interventions within the CCM. For example, teams described linkages
with community-based resources ranging from promotion of home
gardening and local foods in Chuuk to improvements in screening and
outreach services in Kosrae, Pohnpei, and Yap. Additionally, teams
worked to orient administrative leadership to the CCM with sites
reporting expanded support for integrating multidisciplinary teams,
ordering needed supplies/equipment, and maintaining access for
health-care specialist support. All sites reported enhancement of selfmanagement support systems including cross training of staff in
self-management goal setting and monitoring. Other interventions
consistently described by participating teams included redesign of NCD
(e.g., diabetes) clinics, provision of continuing medical education to
health-care staff (i.e., evidence-based standards of care, foot exams,
and oral health screening), and the launching of the CDEMS.
Pilot Interventions and Evaluation
Lessons Learned
The NCD Collaborative pilot’s application of the CCM, under the
leadership of PCDC and local health professional trainers, has shown
encouraging outcomes and lessons learned. Each team reported
improvements in diabetes self-management goal setting and support
(i.e. use of community health workers, patient reminder systems, and
community linkages) a key element of diabetes care, critical to reducing
the risk of diabetes related complications and improving quality of life.
During the 18-month pilot, most teams also shared improvements in
baseline
measures, across several clinical performance measures including blood
pressure control, foot and dental exams, and flu vaccinations. Several
sites note a one-percentage point (or near) drop in average A1c in their
populations of focus. Although, some sites (i.e. Kosrae, Yap, and Majuro)
described challenges in achieving recommended A1c measures (i.e. two
per year; 3 months apart) because of lack of reagents, quality control
issues, laboratory staff turnover, or delays in establishing an
interdisciplinary collaborative team.
These pilot outcomes are encouraging, as research has
confirmed, that for people with diabetes, blood pressure
control (e.g. <140/80 mmHg) reduces the risk of
cardiovascular disease by 33% 8 to 50% and the risk of
micro vascular complications (i.e., eye, kidney, and nerve
diseases) by approximately 33%. Additionally,
comprehensive foot-care programs (i.e., screening exams,
foot-care education, and preventive therapy) can reduce
amputation rates by 45% to 85%. In general, every
percentage point drop in A1c (e.g., from 8.0% to 7.0%)
reduces the risk of diabetes related eye, kidney, and nerve
diseases by about 40%12,
Additionally, feedback from participating teams (across the 18-month
pilot) have identified key lessons that contributed to the pilot efforts’
success and may be applicable to sustainability and continued reach
of the NCD collaborative within the USAPI. Examples of lessons
learned include:
● Ministers and Directors of Health who were engaged in the
collaborative process provided support in leveraging and sustaining
systems change across the CCM elements.
● Community partners (multi-sector) enhanced the availability of selfmanagement support and resources.
●Active participation and commitment to the collaborative (i.e.
engagement in all learning sessions and action periods) by team
members (i.e., physician champion, team leader, and data person) is
critical for continuity of the CCM learning process and subsequent
system improvements.
●Regional, federal, and international partnerships served to
maximize support of the collaborative and accelerate NCD
related quality care improvement.
●Involvement of content-experts (familiar with approaches
to NCD prevention and management in low-resources
settings) helps strengthen and accelerate consensus
development and adoption of standards of care and
evidence-based practices within
collaborative sites
● Availability of supplies and resources to support primary
health-care interventions (i.e. laboratory reagents and
specialty-care) are essential in targeting reduction of NCD
related complications.
● A network of local trainers promoted learning and team
collaboration. Building local trainer skills in providing
technical support and coaching may be strategic in
sustaining collaborative teams within the region.
●Use of available information technology (e.g., CDEMS)
enabled team members to input data and review detailed
reports on laboratory and screening exam results,
medications, co morbid conditions, and scheduled visits
for their population of focus.
● Continued CDEMS training and problem solving may
help expand the tracking and monitoring of quality
measures for individual and population level NCD
prevention and management within the region.
16 Team Members received their certificates
and are now NCD Collaborative Trainers
Chuuk State
Kosrae State
Pohnpei State
Yap State
Waab Community Health Center
Majuro, RMI
Conclusion
Collaborative efforts, using local trainers and the CCM
framework, can improve NCD prevention and
management within USAPI communities. The PCDC’s
NCD collaborative pilot within the Federated States of
Micronesia and Majuro, RMI has provided essential
lessons learned to help sustain achievements and
improve reach across the region. Focus areas for
continued development of the NCD Collaborative
include: engagement of senior management;
developing local leadership and mentoring
opportunities; educating health-care teams about
standards of care; and providing CDEMS support and
technical assistance.
U.S. Associated Pacific Islands
Non-Communicable Disease Collaborative Guidebook
June 2015