Chronic disease management in Andalusia region, Spain

iChronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia7: OPIMEC8: Future challenges

1Chronic Disease1: Quick facts

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.




“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”



http://www.natpact.nhs.uk



http://www.albertahealthservices.ca



http://www.natpact.nhs.uk



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



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

2Chronic Disease1: Quick facts2: Approaches




http://www.paho.org



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.

http://www.who.int/gb/ebwha/pdf_files/WHA53/ResWHA53/17.pdf



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

3Chronic Disease1: Quick facts2: Approaches3: Results



0

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60

92/93

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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



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

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1995 1996 1997 1998 1999 2000 2001 2002 2003

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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



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

4Chronic Disease1: Quick facts2: Approaches3: Results4: Models



“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



Levels of health care for people with chronic disease



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?



Chronic Disease Management and Shared Care

Self care

Professional care



Core elements of the continuum of chronic disease prevention and care



Wagner EH et al. Manag Care Q 1997;7:56-66

The Chronic Care Model (CCM)



The Innovative Care for Chronic Conditions (ICCC) framework.

Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305

5Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT



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%)



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



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



Benefits of better chronic disease management

6Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia



http://www.juntadeandalucia.es/salud

Quality Plan for the Public Health Care System of Andalusia



“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



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



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



Hospitalized patients:

Only 15% have a single defined medical problem

Average of comorbidity in elderly people (>65): 6,4 chronic diseases



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



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



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



http://www.juntadeandalucia.es/salud



Liaison nurses:

• 309 professionals • 225,254 home visits in 2009



Andalusian Plan for supporting Family caregivers:

• 118,162 caregivers • 85% women• Average age 60 years old• 60% of cases single caregiver



Patient‘s School



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)



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

http://images.google.es/imgres?imgurl=http://www.nostrallar.com/images/enfermera.jpg&imgrefurl=http://www.nostrallar.com/ct/servicios.html&h=300&w=200&sz=8&hl=es&start=7&tbnid=oto9R_jPWEo8GM:&tbnh=116&tbnw=77&prev=/images%3Fq%3D%2522enfermera%2522%26svnum%3D10%26hl%3Des%26lr%3D%26sa%3DG



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



People studied: 140,892With retinopathy: 31,306



Vaccines AppointmentsWarningsAdvices

Users: 14,720Total SMS: 180,435

http://images.google.es/imgres?imgurl=http://www.antena3.com/a3n/a3n_contenidos/contenidos/3/3/omnjr4447-00020.jpg&imgrefurl=http://www.antena3.com/a3noticias/servlet/Noticias%3Fdestino%3D../a3n/noticia/noticia.jsp%26sidicom%3Dsi%26id%3D11663982&h=288&w=352&sz=12&hl=es&start=6&tbnid=0IZ8MyIGbMjjaM:&tbnh=94&tbnw=116&prev=/images%3Fq%3Dvacunacion%26svnum%3D10%26hl%3Des%26lr%3D%26sa%3DG



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

Health Care Information and Management Integrated System Health Care Information and Management Integrated System



62.763

48.753

0

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20000

30000

40000

50000

60000

70000

SEP-05 SEP-06

-22.32%

GP consultations before and after electronic prescription



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

7Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia7: OPIMEC

8Chronic Disease1: Quick facts2: Approaches3: Results4: Models5: SWOT6: Andalusia7: OPIMEC8: Future challenges



Continuity of Patient Care

Chronic diseases:A Challenge for Healthcare



Proactive Healthcare System

EffectiveSelf-managementSupport

Chronic disease management in Andalusia region, Spain

Health & Medicine

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