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Key note lecture at EGPRN meeting Ljubljana, May 2012

Key note lecture at EGPRN meeting Ljubljana, May 2012



Presentation on the importance not to loose perspective on holistic and comprehensive apporach in managing pateints with chornic conditions.

Presentation on the importance not to loose perspective on holistic and comprehensive apporach in managing pateints with chornic conditions.



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    Key note lecture at EGPRN meeting Ljubljana, May 2012 Key note lecture at EGPRN meeting Ljubljana, May 2012 Presentation Transcript

    • Quality Improvement in the Care ofChronic Disease in Family Practice: thecontribution of education and research Professor Janko Kersnik, MD, MSc, PhD Head of Research Department, Department of Family Medicine, Medical School Ljubljana Head of Family Medicine Department, Medical School Maribor, Slovenia President of EURACT
    • By the end of the presentation you will Know integrative care model Know traditional care models Know in which way finances and politicians determine health care models Understand professional drive in development of health care models Understand dilemmas in chronic care models Value continuous endeavours for better patient careMay 11, 2012 EGPRN Ljubljana 2
    • Agenda of the presentation 1 Historical background  3 Money and politicians  Holistic approach speak for themselves  Integrative care model  Waiving flags of  Impact of science governments  WHO declarations 2 Traditional care  Financial constrains  Episodic care  Emergency room focus  4 Professional drive  Breaking down to pieces  Family practice education  Medical research  Quality improvementMay 11, 2012 EGPRN Ljubljana 3
    • 1 Historical background Holistic approach Integrative care model Impact of scienceMay 11, 2012 EGPRN Ljubljana 4
    • Holistic approach – where does it comefrom?May 11, 2012 EGPRN Ljubljana 5
    • Holistic approach – we have used it Doctor’s visit Jan SteenMay 11, 2012 EGPRN Ljubljana 6
    • (W)holistic approach SFD are personal doctors, primarily responsible for the provision of comprehensive and continuing care… SFD are trained in the principles of the discipline. One of six core competencies of a specialist family doctor (SFD)**The European definitions of the key features of the discipline of general practice: the role of the GP and core competencies. Justin Allen, Bernard Gay, Harry Crebolder, Jan Heyrman, Igor Švab, and Paul RamMay 11, 2012 EGPRN Ljubljana 7
    • Holistic approach – where does it lead us? SFD deals with health  “If God did not exist, problems in their physical, it would be psychological, social, necessary to invent cultural and existential him.”* dimensions. Dilemmas: how to practice, how to measure, how to pay, how to prove effectiveness, how to “compete” complementary and alternative medicine in holism…  *VoltaireMay 11, 2012 EGPRN Ljubljana 8
    • Integrative care modelMay 11, 2012 EGPRN Ljubljana 9
    • Where do the demands for integrative caremodels come from? Before industrial revolution – an emperor need for numerous and healthy armies to plunder other nations and protect own state. Industrial revolution – an owner need for healthy workers for profit production. Post-industrial era – a state need for consumers of abundance of products. Philosophically – a human right for quality health care.May 11, 2012 EGPRN Ljubljana 10
    • A comprehensive health care model basedon Andrija Štampar public healthparadigm Community based Active approach Team-work Health promotion, education and disease prevention Early disease detection and treatment Continuous disease management and palliation of patients on the listsMay 11, 2012 EGPRN Ljubljana 11
    • Andrija Štampar, Croatia Public health expert of the Health Organization before Second World War President of World Health Organization AssemblyMay 11, 2012 EGPRN Ljubljana 12
    • A merge of political and health caretheories in Yugoslavia One component of practical implementation of Marxism is nationalisation of all resources, government becoming one big capitalist. In this ideology health care becomes a buffer of social justice and a parading horse of the regime. Practical consequences are universal coverage, good accessibility and availability, setting priorities, decentralisation and primary care focus.May 11, 2012 EGPRN Ljubljana 13
    • Divergences in proclamations andpractices WHO – 1978 Alma Ata  Eastern Europe – declaration on primary policlinics care  Yugoslavia – Health for all subspecialisation of Primary health care doctors in primary care now more then ever clinics  Western Europe – specialist dominated care  UK - GPMay 11, 2012 EGPRN Ljubljana 14
    • Impact of scienceMay 11, 2012 EGPRN Ljubljana 15
    • Driving forces of science? New knowledge New technologies New sub- specialisations Breaking down a human body to the smallest pieces Who can fix a broken jar of humanism?May 11, 2012 EGPRN Ljubljana 16
    • 2 Traditional care Traditional care  Episodic care  Emergency room focus  Breaking down to piecesMay 11, 2012 EGPRN Ljubljana 17
    • Episodic care Traditionally health care at all levels of care was episodic care of a problem encountered in a patient managed in the first and eventually few consecutive visits. Emergence of a number of chronic diseases and technological possibilities to manage them for longer periods of time challenged episodic care and gave room for several models to tackle this issue.May 11, 2012 EGPRN Ljubljana 18
    • Emergency room focus Illness are very unplanned events in human lives. Technical advances in medicine made it possible to cure many serious conditions if implemented in right time. Several financial limitations made emergency care only care available for many patient groups. Focus on emergency care in some countries shifts emphasis from usual family practice care to emergency care.May 11, 2012 EGPRN Ljubljana 19
    • ER medicalisationMay 11, 2012 EGPRN Ljubljana 20
    • Outcomes of traditional BME teaching What would be a typical response of a student to 30-year old female patient presenting with following complaint: “In the past 14 days several times I experienced pain in my chest, tightness in my neck and tingling in my left arm. Nearly every night this wakes me up in the middle of the night. I became worried as I might have died out of that.”May 11, 2012 EGPRN Ljubljana 21
    • Breaking down to pieces Necessary subspecialisation of medical profession brought us to situations, when each medical profession can only check its piece of human body, ignoring a person.May 11, 2012 EGPRN Ljubljana 22
    • An urgent need for a comprehensivechronic care model? Wagner’s Chronic Care Model (broad conceptual model),, chronic disease management → expanded chronic care model Kaiser’s triangle (service delivery model), Evercare (service delivery model), Unique Care / Castelfields (service delivery model), NPDT collaborative eg. on COPD (service delivery model), Expert Patient Programme (service delivery model), Pursuing Perfection (service delivery model), PARR tool developed by King’s Fund (service delivery model).…May 11, 2012 EGPRN Ljubljana 23
    • Canadian chronic care modelMay 11, 2012 EGPRN Ljubljana 24
    • Canadian expanded chronic care modelMay 11, 2012 EGPRN Ljubljana 25
    • UK chronic disease management modelMay 11, 2012 EGPRN Ljubljana 26
    • 3 Money and politicians speak forthemselves Waiving flags of governments WHO declarations Financial constrainsMay 11, 2012 EGPRN Ljubljana 27
    • Waiving flags of governments Health care systems were waiving flags of governments when communicating with citizens in Eastern countries. UK: Good chronic disease management offers real opportunities for improvements in patient care and service quality, and reductions in costs.May 11, 2012 EGPRN Ljubljana 28
    • WHO declarations Primary health now more than ever.May 11, 2012 EGPRN Ljubljana 29
    • Financial constrains There is always greater demand than resources available. Cost-containment is one of the key elements of chronic disease models. Computers are filled with better outcomes on indicators. Chronic disease models are payer/government driven and may disrupt comprehensive family practice approach.May 11, 2012 EGPRN Ljubljana 30
    • 4 Professional drive Family practice education Medical research Quality improvementMay 11, 2012 EGPRN Ljubljana 31
    • Family practice education Performs chronic carePerformance = Works as a “team”DOES Shows skills for managementCompetence = of chronic patientsSHOWS HOW Shows skills for teamworkSkills = Possess skills forKNOWS HOW management of chronic patientsKnowledge = Possess skills for teamworkKNOWS Knows chronic care models “Knows” chronicity May 11, 2012 EGPRN Ljubljana 32
    • 30-year old female patient Student: acute coronary syndrome Theory: What are differential diagnoses? Practice: Direct observation of this consultation Chinese proverb: “I see and I remember.” Discussion Reflection Trying outMay 11, 2012 EGPRN Ljubljana 33
    • The European definitions of the key features of the disciplineof general practice: the role of the GP and core competencies.Justin Allen, Bernard Gay, Harry Crebolder, Jan Heyrman, IgorŠvab, and Paul RamMay 11, 2012 EGPRN Ljubljana 34
    • Educational agenda to provide longitudinal continuity of care as determined by the needs of the patient, referring to continuing and co-ordinated care management; to co-ordinate care with other professionals in primary care and with other specialists; to master effective and appropriate care provision and health service utilisation; to communicate, set priorities and act in partnership; to promote health and well being by applying health promotion and disease prevention strategies appropriately…May 11, 2012 EGPRN Ljubljana 35
    • We know, but what do students say… “I was aiming to continue as surgeon and I was blinded by big city FP, that FP do not perform a lot of medicine, but after working with your tutor in his practice, I saw, what could be provided to patients in FP…” “You should continue to teach us communication skills, train to think from broader perspective and show us common patients’ problems…” “After standing your tutorship in your practice, I feel confident to answer any question…” “I changed my specialty training from anaesthesiology to FM, because I wanted to talk to people.”May 11, 2012 EGPRN Ljubljana 36
    • Medical research on chronic care models Quality of care Clinical outcomes Resource use “While there is evidence that single or multiple components of chronic care model can improve quality of care, clinical outcomes, and healthcare resource use, it remains unclear whether all components of the model, and the conceptualisation of the model itself, is essential for improving chronic care.”**Improving care for people with long-term conditions. http://www.improvingchroniccare.org/downloads/review_of_international_frameworks__chris_hamm.pdfMay 11, 2012 EGPRN Ljubljana 37
    • Quality improvement The totality of evidence suggests that applying components of these models may improve quality of care for people with many different long-term conditions, but it remains uncertain which components are most effective or transferable.May 11, 2012 EGPRN Ljubljana 38
    • IT in chronic careMay 11, 2012 EGPRN Ljubljana 39
    • Challenges in chronic care Professionalism Ethical issues Team work Societal needsMay 11, 2012 EGPRN Ljubljana 40
    • Professionalism in chronic care What comes first? Am I forced by chronic care model to look through a EURO or am I really following professional standards? “Doctors shouldn’t be dependant on patients’ money.”May 11, 2012 EGPRN Ljubljana 41
    • Ethical issues Who comes first? Am I forced to neglect patient privacy and autonomy to get quality data into my computer? Doctors should have protected role in the society regarding keeping patient privacy.May 11, 2012 EGPRN Ljubljana 42
    • Team work Who leads my team? Am I prepared for shared decision making with other professionals in my team and am I trained (interprofessionally) to do so without a conflicts for the best of our patients? Teams should have a dynamic leadership depending on the patient issue, which the team deals with.May 11, 2012 EGPRN Ljubljana 43
    • Societal needs Who determines the foundation of the society? Am I prepared to promote and keep core values of medicine against current political and economic winds of everyday practice if they are in conflict? Doctors should be able to keep the pressure of unsolicited changes and to change their practices as appropriate.May 11, 2012 EGPRN Ljubljana 44
    • Conclusions One of the key points of our future endeavours in quality improvement are in meaningful translating high science to meaningful recommendations and translating some high-tech diagnostics and treatments to primary care level. We should keep in mind that different models are coming and passing, but continuity of care of our (chronic) patients remains our continuous educational, research, quality in practice task.May 11, 2012 EGPRN Ljubljana 45
    • Thank you very much foryour attention!