Chronic disease management in Andalusia region, Spain

i
Chronic Disease
1: Quick facts
2: Approaches
3: Results
4: Models
5: SWOT
6: Andalusia
7: OPIMEC
8: Future challenges

1
Chronic Disease
1: Quick facts

Calidad de la atención a personas con
múltiples enfermedades crónicas:
nuevas oportunidades y desafíos

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.

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”



http://www.natpact.nhs.uk


http://www.albertahealthservices.ca


National Health Survey: 18 million people report a Chronic disease
National Disability Survey: 3.85 Million people (8.5% Spanish pop.)

Personas con
2,2 discapacidad de más de
65 años
Personas con
1,5 discapacidad hasta 65
años

0 0,5 1 1,5 2 2,5
Millones de personas

http://www.ine.es/infoine


Chronic Disease in Andalusia

2.88 Million people with chronic conditions

965,400 depression or other mental disorders
472,700 diabetic patients
333,400 COPD
322,100 CHF
163,900 ischemic heart disease
139,000 Cancer

http://www.ine.es/inebase/cgi/axi

2
Chronic Disease
1: Quick facts
2: Approaches


http://www.paho.org


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/topics/chronic_diseases/en/


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

3
Chronic Disease
1: Quick facts
2: Approaches
3: Results


Castlefields Health Centre
Cardiac events
60

50
40
Non-fatal Mis
30
IHD Deaths
20

10
0

02
3

4

5

6

7

8

9

0

1
/9

/9

/9

/9

/9

/9

/9

/0

/0

1/
92

93

94

95

96

97

98

99

00

'0

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
100

80

60 >10
<10
40 <7.5

20

0
1995 1996 1997 1998 1999 2000 2001 2002 2003

http://www.natpact.nhs.uk/cms/328.php
Lyon D et al. J Integ Care 2006;14:7-12


Patients participating in DM:

Lower rate of:
- Inpatient hospital stays
- Inpatient days
- Emergency room visits
- Outpatient visits

http://www.floridahealthy.org
Afifi AA et al. Preventive Medicine 2007


Prevents late referral Improves preparation
Late Referral (<4 Months Prior to ESRD) Fistula Present, Start of Hemodialysis

32% 48%
44%
39%

19% 29%
16%
11%

KPHI 2004 KPHI 2005 KPHI 2006 KPHI 2007 2004 2005 2006 2007

Improves appropriate referrals Slows progression to ESRN

4
Chronic Disease
1: Quick facts
2: Approaches
3: Results
4: 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, Professionals and patients have
patients inexperienced complementary knowledge and experiences

Kane RL. Ageing Clin Experiment Res 2002


Levels of health care for people with chronic disease


• Over 80% of all medical symptoms
Professional Care are self-diagnosed and self-treated
20% without professional care.

• Patients are the true primary care
providers of medical care for
themselves and their families.

• How can health care systems
Self-Care educate, equip, and empower the true
primary care providers… patients?
80%


Chronic Disease Management and Shared Care

Pr
ofe
ssi
on
al
Se ca
lf c re
are


Core elements of the continuum of chronic disease prevention and care


The Chronic Care Model (CCM)

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


The Innovative Care for Chronic Conditions (ICCC) framework.

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

5
Chronic Disease
1: Quick facts
2: Approaches
3: Results
4: Models
5: 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


Likely benefits of better chronic disease management

Increased Decreased

Control of their own Complications from their
condition chronic disease

Feeling of well being Unnecessary hospital
admissions
Ability to cope day to day
Sense of powerlessness


Benefits of better chronic disease management

6
Chronic Disease
1: Quick facts
2: Approaches
3: Results
4: Models
5: SWOT
6: Andalusia


Quality Plan for the Public Health Care System of Andalusia

http://www.juntadeandalucia.es/salud


Process reengineering:
Integrated Care
Processes
…much more than
Clinical Practice Guidelines

“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”


Integrated Care Processes:
Basis and Key elements
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


IDEF Methodology
(Integrated definition for Function Modeling)

Process
Sub-processes
Activities
Identifying at each
Tasks step Who, When,
Where and How

Using systematically
Evidence-Based Clinical
Practice Guidelines

Generating indicators and
standards of structure,
process and outcomes


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 model
Objective: Improve quality, equity, effectiveness and efficiency of healthcare
How: Shifting management responsibility to the professionals
Where: In the Clinical Management Units: flexible multidisciplinary teams
Key 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

Human
resources
Key
Leadership Strategy Processes Satisfaction Results
Resources
& alliances

Agents Results


Clinical Management Roadmap

Identify a clinical leader
Define the service basket of the unit
Identify the process map of the unit
Create a system to collect citizen’s expectations
Have a result-oriented information system
Set an Improvement Plan with concrete objectives
Capacity 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


BMJ, doi:10.1136/bmj.39156.536968.55 (published 10 April 2007)

RESEARCH

Telemonitoring or structured telephone support
programmes for patients with chronic hearth failure:
systematic review and meta-analysis
Robyn A. Clark, Sally C. Inglis, Finlay A. McAlister, John G.F. Cleland,
Simon Stewart

http://www.bmj.com


Heath Wave Response Plan
Weather
forecast
Daily alert
level

Health Responds
People at risk: 5,821
Total Calls: 42,964

Emergency Coordination Centre

Hospital Emergency Room Family nurse People at risk


Living
wills

Second
Medical
Opinion Centralized
appointment Smart cards
Waiting
Internet appointment
lists
Health Responds
Information and Services Centre
20,000
Information
daily
Telephone
appointment
100,000
daily
Electronic
prescription Virtual Office (InterS@S)


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


Users: 14,720
Total SMS: 180,435

Vaccines Warnings Appointments
Advices


Transparency .
Tobeinformed is health Health Responds
Education Web Telephone enquiries
Information TV/DTV Second medical opinion
entertainement Mobile Iiving wills
Health card
Waiting lists
Telephone appointment
Healthcare information
Health advices
Information on Quality in
Discharge telephone survey
Health Centres
AIDS, Tobacco, bird flu...
Expectations bank
SMS services
Healthcare Information
Health Advices

Collection of Expectations
to promote participation
e-Administration
Living wills
Smart card
24
health andalusia
hr

Individual assessment and
and information information on Health

Health Care Information and
Management Integrated System


70000
62.763

60000
48.753
-22.32%
50000

40000

30000

20000

10000

0
SEP-05 SEP-06
GP consultations before and after electronic prescription


Health Direct Clinical
liaison phone for pathways
nurses fragile
patients
Clinical
Management
family
Units
caregivers
Integrated
Patient’s Plans
school

Multi-channel eHR
information
Quality
Rehabilitation certification
plan
e- Shared
Prescription on-line incentives
HTA Palliative
care plan

7
Chronic Disease
1: Quick facts
2: Approaches
3: Results
4: Models
5: SWOT
6: Andalusia
7: OPIMEC

8
Chronic Disease
1: Quick facts
2: Approaches
3: Results
4: Models
5: SWOT
6: Andalusia
7: OPIMEC
8: Future challenges


Continuity of Patient Care

Chronic diseases:
A Challenge for Healthcare


Proactive
Healthcare
System

Effective
Self-management
Support

Chronic disease management in Andalusia region, Spain

Chronic disease management in Andalusia region, Spain

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