Post on 29-May-2018
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Chronic Disease: The Challenge of ImplementationChronic Disease: The Challenge of Implementation
Rafael Bengoa,Basque Government.Spain
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1992 1997 2002 2007
Evolution of diabetes and cardiovascular disease in the Basque Country%
4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0
here too
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Going Fast
Mokdad AH, et al. JAMA 282:16, 1999, and 286:10, 2001.
1990 1995 2001
No Data 10%
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SAME PATTERN AS OTHER COUNTRIESSAME PATTERN AS OTHER COUNTRIES
Ninguno
Uno
Dos
Tres o ms
23,5 %
8,6 %
28,9 %
39,1 %
Ninguno
Uno
Dos
Tres o ms
23,5 %
8,6 %
28,9 %
39,1 %
Fuente: ESCAV 2007
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Medical consultations/capita. Europe. 2003Medical consultations/capita. Europe. 2003
0
2
4
6
8
10
Gre Sue P or Fin UK P b I ta Lux I rl Aus Fra Ale Din Bel Esp
5.95.92.52.5
9.59.5
European CountriesEuropean CountriesEcosalud. OCDE 2005.Ecosalud. OCDE 2005.
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The drivers.
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! Prevention !! Prevention !
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Medical Consultations / Capita. European CountriesMedical Consultations / Capita. European Countries
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FragmentationFragmentation
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80% interventions
3 our of 4 deaths in 2020
77% Expenditure
2/3 of growth in expenditure
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Intervene across the Continuum of CareIntervene across the Continuum of Care
$
0 40 8020 60 Age
Healthy/Low Risk At Risk High Risk
Active
Disease
Severe
Disease
HealthPromotion
Primary Prevention
Secondary Prevention &Disease Management
Complex CaseManagement
PalliativeCare
$ ?
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Estratificacin del riesgo
Gestinde casoscomplejos
Gestin dela Atencin
Apoyo a la autogestin
Estratificacin del riesgo
Gestinde casoscomplejos
Gestin dela Atencin
Apoyo a la autogestin
Sistema de SaludOrganizacion de atencion
sanitaria
Auto
gestin
Diseo
sistemaprestacin
Apoyo a
ladecision
Sistemas de
informacinclinica
ComunidadRecursos yPoliticas
Equipo desalud
Proactivo
PacienteInformado
Activado
Resultados Clnicos y Funcionales
InteraccionesProductivas
Sistema de SaludOrganizacion de atencion
sanitaria
Auto
gestin
Diseo
sistemaprestacin
Apoyo a
ladecision
Sistemas de
informacinclinica
ComunidadRecursos yPoliticas
Equipo desalud
Proactivo
PacienteInformado
Activado
Resultados Clnicos y Funcionales
InteraccionesProductivas
Some Frameworks ..
HowHow can (chronic care) performance be enhancedcan (chronic care) performance be enhanced
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Estratificacin del riesgo
Gestinde casoscomplejos
Gestin dela Atencin
Apoyo a la autogestin
Estratificacin del riesgo
Gestinde casoscomplejos
Gestin dela Atencin
Apoyo a la autogestin
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HowHow can (chronic care) performance be enhancedcan (chronic care) performance be enhanced
From Improving Chronic Illness CareEd Wagner, MD, Group Health Cooperative of Puget Sound
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UC Berkeley StudyUC Berkeley StudyUse ofUse of Care Management ProcessesCare Management Processes by Type of Chronic Conditionby Type of Chronic Condition
Type of CMPsType of CMPs DiabetesDiabetes
(n = 523)(n = 523)++AsthmaAsthma
(n = 522)(n = 522)
CHFCHF
(n = 526)(n = 526)
DepressionDepression
(n = 497)(n = 497)
Each of 4Each of 4
Chronic IllnessChronic Illness
It TreatsIt Treats
(n = 491)(n = 491)
Patient list or registryPatient list or registry 70.2%70.2% 62.4%62.4% 58.5%58.5% 40.8%40.8% 39.1%39.1%
Provide patient educatorsProvide patient educators 73.9%73.9% 53.8%53.8% 53.6%53.6% 35.4%35.4% 30.5%30.5%
Physician feedback on qualityPhysician feedback on quality 66.1%66.1% 56.1%56.1% 50.8%50.8% 32.8%32.8% 30.9%30.9%
Nurse care managersNurse care managers 54.7%54.7% 42.7%42.7% 47.5%47.5% 25.1%25.1% 23.8%23.8%
Patient remindersPatient reminders 51.4%51.4% 35.2%35.2% 35.0%35.0% 19.7%19.7% 19.1%19.1%
PointPoint--ofof--care reminderscare reminders 51.2%51.2% 36.4%36.4% 33.1%33.1% 22.9%22.9% 19.5%19.5%
No. (%) using all 6 CMPsNo. (%) using all 6 CMPs 21.6%21.6% 10.5%10.5% 10.1%10.1% 4.4%4.4% --
No. (%) using all 24 CMPsNo. (%) using all 24 CMPs -- -- -- -- 3.7%3.7%
Mean CMP Use (out of 6)Mean CMP Use (out of 6) 3.73.7 2.92.9 2.82.8 1.81.8 --
Mean CMP Use (out of 24)Mean CMP Use (out of 24) -- -- -- -- 11.111.1
Source: D. Rittenhouse et al., Improving Chronic Illness Care: Findings From NationalStudy of Care Management Processes in Large Physician Practices, 2009, Under Review.
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Our system needs changesOur system needs changes
No risk stratificationNo risk stratification
No case nursesNo case nurses
No routine clinical remindersNo routine clinical reminders
No continuum of careNo continuum of care
No activated patientNo activated patient
No regular telemonitoringNo regular telemonitoring
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VA Continues to Exceed HEDIS in 2008VA Continues to Exceed HEDIS in 2008
INDICATORINDICATOR VA 2008VA 2008 VA 2007VA 2007 CommercialCommercial
20072007MedicareMedicare
20072007MedicaidMedicaid
20072007
Breast cancer screeningBreast cancer screening 87%87% 86%86% 69%69% 67%67% 50%50%
Cervical cancer screeningCervical cancer screening 92%92% 91%91% 82%82% n/an/a 65%65%
Colorectal cancer screeningColorectal cancer screening 79%79% 78%78% 56%56% 50%50% n/an/a
LDL Cholesterol < 100 after AMI, PTCA,LDL Cholesterol < 100 after AMI, PTCA,
CABGCABG66%66% 62%62% 59%59% 56%56% 38%38%
Diabetes: DM control HbA1cDiabetes: DM control HbA1c
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Moving 14 Strategic ProjectsMoving 14 Strategic Projects
Populationstratification
Populationfocus
Prevention andpromotioninterventions
Prevention andpromotion
Expert patient
Patientautonomy
Unified healthrecords
Integratedclinical care
New nurse roles
Socio-healthcontinuum
Financing &commisioning
Continuum ofcare
Multichannelservice center
E-Prescription
Telemonitoringexperiences
Chronic careinfrastructures
Chronic careinnovation center
Personalizedinterventions
Clinical innovation
Visin
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Innovacin desde los
profesionales Generacin de15-25 proyectos de innovacinal ao y extensin de los que
demuestren resultados (~90%)
Centro Servicios Multicanal
Despliegue en Euskadi detodos los servicios para
mediados de 2013
Prevencin y Promocin
Prevencin de aparicin ydesarrollo de
enfermedades crnicas(De_Plan, prevencin
tabquica)
Estratificacin
Estratificacin operativade la poblacin vasca de
forma sistematizada yperidica desde 2011
Autocuidado
Experiencias en lasprincipales enfermedadescrnicas, potenciando la
adherencia y el usoapropiado de los recursos
Historia Clnica
unificada
Implantacinuniversal a finales
de 2011
Atencin clnica
integrada
Un tercio de lasorganizaciones a 2013,
con procesos integrados
Competencias Avanzadas
Enfermera
Formar a 300 enfermerasen los nuevos roles hasta
2013
Receta electrnica
Implantacin efectiva delsistema de receta electrnica
en todo Euskadi en 2012 2013
Experiencias de
telemonitorizacin
Monitorizacin a distancia del 1%de enfermos crnicos severos
(~22.500)
Financiacin y Contratacin
Implantacin plena de unsistema de asignacin
financiera
territorial ajustada
por riesgo
Modelo hospitales subagudos
Implantacin del modelo enhospitales de media estancia ycreacin de nuevo hospital de
crnicos en lava
Centro Investigacin
Cronicidad
Ser un referente internacionalen el conocimiento sobreenfermedades crnicas
Colaboracin sociosanitaria
4 municipios confuncionamiento integrado, 1
hospital con plan de altas conprevencin de dependencia, 1
unidad de ortogeriatra
Strategic Projects: Integrated ApproachStrategic Projects: Integrated Approach
9
2
1
3
4
5
6
1011
8
12
137
14
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Increased use of Technologies : Smart HomeIncreased use of Technologies : Smart Home
Rememberyour
medicine
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WE WILL PROBABLY ALL END UP WITH SOME SORT OFWE WILL PROBABLY ALL END UP WITH SOME SORT OFSTRUCTURED PATIENT EDUCATION : BOTH DIRECT ANDSTRUCTURED PATIENT EDUCATION : BOTH DIRECT AND
REMOTEREMOTE
REMOTE PATIENT
EDUCATION
PATIENT EDUCATION
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With some sort of case manager ( Nurse )With some sort of case manager ( Nurse )
nn Nurses who act a caseNurses who act a case
managers for patients withmanagers for patients with
complex conditions.complex conditions.
nn Their function will be toTheir function will be to
evaluate their physical andevaluate their physical and
social needs and coordinatesocial needs and coordinatetheir care.their care.
Estratificacin del riesgo
Gestinde casoscomplejos
Gestin dela Atencin
Apoyo a la autogestin
Estratificacin del riesgo
Gestinde casoscomplejos
Gestin dela Atencin
Apoyo a la autogestin
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The payoffThe payoff
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
1Q07
2Q07
3Q07
4Q07
1Q08
2Q08
3Q08
4Q08
1Q09
2Q09
3Q09
4Q09
Registered members
Lab test resultsviewed online
E-mails sent toproviders
Visits to past visitinformation
Online prescriptionrefills
52.6 M
3 M
20.8 M
Source KP
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Change Process:Too Mechanic ??
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Evidence increasing around a few thingsEvidence increasing around a few things
nn Different diseases , similar needs and similar solutionsDifferent diseases , similar needs and similar solutions
nn It is a cultural change: It is deep. It is about the wayIt is a cultural change: It is deep. It is about the waywe work and behaviourwe work and behaviour
nn To pull this off you need patients and staff on board.To pull this off you need patients and staff on board.
nn It is therefore less about structural moves than aboutIt is therefore less about structural moves than aboutstaff engagementstaff engagement
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StrategyStrategy
SystemsSystems StructureStructure
Skil lsSkil ls
ValuesValues LeadershipLeadership
STAFFSTAFF
WHERE IS THE CHALLENGE FOR POLICY MAKERS?WHERE IS THE CHALLENGE FOR POLICY MAKERS?
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Top downTop down
Not acceptedNot accepted
Not adaptedNot adapted
No scaleNo scale
No alignmentNo alignment
Bottom upBottom up
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Abandon a Hierarqu ical CultureAbandon a Hierarqu ical Culture
--Apparent stabilityApparent stability
-- Rules y regulationsRules y regulations
-- Simplistic for organizations and problems of todaySimplistic for organizations and problems of today-- PoliticizedPoliticized
Build aBuild a DevelopmentDevelopmentCultureCulture
--Accept complexity and diversityAccept complexity and diversity
-- Promote Local experimentation/researchPromote Local experimentation/research
-- ProvideProvidespacespaceand local autonomyand local autonomy
-- Work with pioneers and early adoptersWork with pioneers and early adopters
-- Better balance top down and bottom upBetter balance top down and bottom up
S Si l f llS Si l f ll
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nn
Evidence growing around a few thingsEvidence growing around a few things
nn Policy makers need to bring this up to first divisionPolicy makers need to bring this up to first division
nn Therefore need to intervene in an aligned way acrossTherefore need to intervene in an aligned way across
macromacro, meso and micro levels, meso and micro levels
nn The power of results. Evidence growing but scalabilityThe power of results. Evidence growing but scalability
still an issuestill an issue
Some Signals for allSome Signals for all
Alignment !
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Meso
Macro
Micro
Alignment !
++++
++++