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iChronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia7: OPIMEC8: Future challenges
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1Chronic Disease1: Quick facts
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.euro/who/int
Chronic diseases are diseases of long duration and generally slow progression. Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading cause of mortality in the world, representing 60% of all deaths. Out of the 35 million people who died from chronic disease in 2005, half were under 70 and half were women.
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.euro/who/int
“Health care systems world wide are faced with the challenge of responding to the needs of people with chronic medical conditions
such as diabetes, heart failure and mental illness”
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.natpact.nhs.uk
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.albertahealthservices.ca
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.natpact.nhs.uk
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
National Health Survey: 18 million people report a Chronic diseaseNational Disability Survey: 3.85 Million people (8.5% Spanish pop.)
http://www.ine.es/infoine
1,5
2,2
0 0,5 1 1,5 2 2,5
Millones de personas
Personas condiscapacidad de más de65 añosPersonas condiscapacidad hasta 65años
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Chronic Disease in Andalusia
2.88 Million people with chronic conditions
965,400 depression or other mental disorders472,700 diabetic patients333,400 COPD322,100 CHF163,900 ischemic heart disease139,000 Cancer
http://www.ine.es/inebase/cgi/axi
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2Chronic Disease1: Quick facts2: Approaches
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.euro/who/int
http://www.paho.org
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.who.int/topics/chronic_diseases/en/
WHA53.17 - Prevention and control of noncommunicable diseases
The areas of work of the WHO Integrated Chronic Disease Prevention and Control Programme (ICP), which is one of the technical programmes within the Department of Chronic Diseases and Health Promotion (CHP), include: to raise awareness for chronic noncommunicable diseases and ensure that chronic noncommunicable disease prevention is included in and placed on top of the agenda of health care policies; to promote development and implementation of national policy & strategy, programmes, community-based demonstration projects for prevention and control of chronic diseases with a special focus on developing countries; to promote the development of regional networks of national chronic noncommunicable disease prevention programmes; to promote collaboration and coordination of chronic noncommunicable disease prevention and control activities within and among WHO Regions; to link regional networks and international partners with the Global Forum to promote collaboration for chronic noncommunicable disease prevention and control; to encourage the dissemination of scientific knowledge, experiences and best practices; to develop guidance packages for chronic noncommunicable disease prevention and control; and to stimulate training and capacity building.
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.euro.who.int/__data/assets/pdf_file/0008/96632/E93736.pdf
http://www.euro.who.int/__data/assets/pdf_file/0006/96468/E91878.pdf
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3Chronic Disease1: Quick facts2: Approaches3: Results
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
0
10
20
30
40
50
60
92/93
93/94
94/95
95/96
96/97
97/98
98/99
99/00
00/01
'01/02
Non-fatal MisIHD Deaths
Castlefields Health Centre Cardiac events
http://www.natpact.nhs.uk/cms/328.php
Lyon D et al. J Integ Care 2006;14:7-12
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Castlefields Health Centre HBA1c in diabetic patients
http://www.natpact.nhs.uk/cms/328.php
Lyon D et al. J Integ Care 2006;14:7-12
0
20
40
60
80
100
1995 1996 1997 1998 1999 2000 2001 2002 2003
>10<10<7.5
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Afifi AA et al. Preventive Medicine 2007
Patients participating in DM:
Lower rate of:- Inpatient hospital stays- Inpatient days- Emergency room visits- Outpatient visits
http://www.floridahealthy.org
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Improves preparationPrevents late referral
Improves appropriate referrals Slows progression to ESRN
Late Referral (<4 Months Prior to ESRD)
32%
19%16%
11%
KPHI 2004 KPHI 2005 KPHI 2006 KPHI 2007
Fistula Present, Start of Hemodialysis
29%
39%44%
48%
2004 2005 2006 2007
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4Chronic Disease1: Quick facts2: Approaches3: Results4: Models
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
“The predominant acute disease paradigm is an anachronism. It is shaped on a 19th
century notion of illness as a disruption of the normal state produced by a foreign presence or external trauma, e.g. infection or injury…. Under this model of acute care is that which directly addresses the threat…. In fact, modern epidemiology shows that the prevalent health problems of today (defined both in terms of costs and health impact) revolve around chronic illness”
Acute disease Chronic disease
Onset Abrupt Generally gradual and often insidious
Duration Limited Lengthy and indefinite
Cause Usually single Usually multiple and changes over time
Diagnosis and prognosis Usually accurate Often uncertain
Technological intervention Usually effective Often indecisive; adverse effects common
Outcome Cure possible No cure
Uncertainty Minimal Pervasive
Knowledge Professionals knowledgeable,
patients inexperienced
Professionals and patients have
complementary knowledge and experiences
Kane RL. Ageing Clin Experiment Res 2002
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Levels of health care for people with chronic disease
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Professional Care20%
Self-Care80%
• Over 80% of all medical symptoms are self-diagnosed and self-treated without professional care.
• Patients are the true primary care providers of medical care for themselves and their families.
• How can health care systems educate, equip, and empower the true primary care providers… patients?
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Chronic Disease Management and Shared Care
Self care
Professional care
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Core elements of the continuum of chronic disease prevention and care
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Wagner EH et al. Manag Care Q 1997;7:56-66
The Chronic Care Model (CCM)
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
The Innovative Care for Chronic Conditions (ICCC) framework.
Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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5Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
CDM Results from Physician Survey
• 82% agreed that CDM tools would be helpful to them in their practices
• Only 24% respondents are currently involved in chronic disease initiatives or programs
• Physicians identified diabetes mellitus (74%) as the top candidate for CDM followed by hypertension (49%) and congestive hearth failure (47%)
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Barriers to Chronic Disease Management
• Time• Complexity• Workload• Remuneration• Human Resources• Medication and polypharmacy• Patient compliance• Co morbidity• Fragmentation of care• Multiple patient visits• Bureaucratic barriers• Lack of focused educational material• Very little training in CDM at the medical school• Lack of appropriate policies• Fragmentation of health care providers
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Increased Decreased
Control of their own
condition
Feeling of well being
Ability to cope day to day
Complications from their
chronic disease
Unnecessary hospital
admissions
Sense of powerlessness
Likely benefits of better chronic disease management
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Benefits of better chronic disease management
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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6Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.juntadeandalucia.es/salud
Quality Plan for the Public Health Care System of Andalusia
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
“Redesign clinical systems across primary care, secondary care, acute care and community care allowing for integration & management of care closer to the citizen. In essence, provide the right care at the right time to with the right provider, first time and every time”
…much more than Clinical Practice Guidelines
Process reengineering: Integrated Care Processes
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
A tool based on Total Quality Management concepts, in order to:- Achieve the satisfaction of users/patients/citizens- Engage all professionals- Promote continuous improvement at lower costs
- Setting out clinical standards- Reducing clinical variability- Providing outcomes measurements
Key elements• Vision centered on the citizen, addressing citizen’s needs• Providing care continuity across the healthcare system• Participation and commitment of professionals• Based on the best available scientific evidence• Supported by an integrated information system
Integrated Care Processes: Basis and Key elements
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Process Sub-processes
Activities
Tasks
IDEF Methodology(Integrated definition for Function Modeling)
Generating indicators and standards of structure, process and outcomes
Identifying at each step Who, When, Where and How
Using systematically Evidence-Based Clinical Practice Guidelines
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Hospitalized patients:
Only 15% have a single defined medical problem
Average of comorbidity in elderly people (>65): 6,4 chronic diseases
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Common features to “pluripathologic” patients
• Several chronic diseases with continuous symptoms and frequent relapses or exacerbations.
• Non curable Diseases• Progressive loss of personnel autonomy and functional capacity ⇒
Disability/Dependency.• Personal, familial, social, economic and labor impact.• Multiple Risks due to merge medical problems: “domino effect” in
descompensations, drug interactions...
FRAGILE, POLIPHARMACY, SEVERAL CONDITIONS, FREQUENT UNPLANNED READMISSIONS, HIGHLY INTENSIVE USER OF SERVICES
THAT SHOWS THE UNSATISFACTORY MODEL OF CARE WE ARE OFFERING TO THESE PATIENTS
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Key elements of Clinical Management
A tool for Organisational Redesign based on EFQM modelObjective: Improve quality, equity, effectiveness and efficiency of healthcareHow: Shifting management responsibility to the professionalsWhere: In the Clinical Management Units: flexible multidisciplinary teamsKey elements:- Professional autonomy of clinical teams. Transference of responsibility. - Outcome oriented. Objectives and incentives by common agreement- Working using Clinical Pathways. Evaluation and benchmark. Information system
Leadership
Humanresources
Strategy
Resources& alliances
Processes SatisfactionKey
Results
Agents Results
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Clinical Management Roadmap
Identify a clinical leaderDefine the service basket of the unitIdentify the process map of the unitCreate a system to collect citizen’s expectationsHave a result-oriented information system Set an Improvement Plan with concrete objectivesCapacity to assume autonomy in decision making
The Clinical Management Agreement
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.juntadeandalucia.es/salud
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Liaison nurses:
• 309 professionals • 225,254 home visits in 2009
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Andalusian Plan for supporting Family caregivers:
• 118,162 caregivers • 85% women• Average age 60 years old• 60% of cases single caregiver
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Patient‘s School
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
http://www.bmj.com
Telemonitoring or structured telephone support programmes for patients with chronic hearth failure: systematic review and meta-analysisRobyn A. Clark, Sally C. Inglis, Finlay A. McAlister, John G.F. Cleland, Simon Stewart
RESEARCH
BMJ, doi:10.1136/bmj.39156.536968.55 (published 10 April 2007)
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
People at risk
Weather forecast
Daily alert level
Emergency Coordination Centre
Heath Wave Response Plan
Hospital Emergency Room
People at risk: 5,821Total Calls: 42,964
Health Responds
Family nurse
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Telephone appointment
Internet appointment
Centralized appointment
Second Medical Opinion
Living wills
Smart cards
Virtual Office (InterS@S)
Health RespondsInformation and Services Centre Information
Waiting lists
Electronic prescription
20,000 daily
100,000 daily
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
People studied: 140,892With retinopathy: 31,306
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Vaccines AppointmentsWarningsAdvices
Users: 14,720Total SMS: 180,435
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
EducationInformationentertainement
Healthcare InformationHealth Advices
Information on Quality in Health Centres
Tobeinformed .is healthTelephone enquiriesSecond medical opinionIiving willsHealth cardWaiting listsTelephone appointmentHealthcare informationHealth advicesDischarge telephone surveyAIDS, Tobacco, bird flu...
SMS servicesExpectations bank
Transparency
e-Administration
Individual assessment andinformation on Health
24 hrhealth andalusia
Collection of Expectationsto promote participationand information
WebTV/DTVMobile
Living willsSmart card
Health Responds
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Health Care Information and Management Integrated System Health Care Information and Management Integrated System
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
62.763
48.753
0
10000
20000
30000
40000
50000
60000
70000
SEP-05 SEP-06
-22.32%
GP consultations before and after electronic prescription
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Clinical Management
Unitsfamily
caregivers
Patient’s school
Multi-channel information
liaison nurses
Clinical pathways
eHR
Health Direct phone for
fragile patients
Integrated Plans
e- Prescription on-line
HTA
Quality certification
Shared incentives
Palliative care plan
Rehabilitation plan
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7Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia7: OPIMEC
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8Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia7: OPIMEC8: Future challenges
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Continuity of Patient Care
Chronic diseases:A Challenge for Healthcare
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Calidad de la atención a personas con múltiples enfermedades crónicas:
nuevas oportunidades y desafíos
Proactive Healthcare System
EffectiveSelf-managementSupport
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