Foro calidad OPIMEC José Luis Rocha

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos “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.euro/who/int

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos http://www.natpact.nhs.uk

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos http://www.albertahealthservices.ca

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos http://www.natpact.nhs.uk

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

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 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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos http://www.euro/who/int http://www.paho.org

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

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

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

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos 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/ 94 95 92 00 93 96 97 98 99 '0 http://www.natpact.nhs.uk/cms/328.php Lyon D et al. J Integ Care 2006;14:7-12

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

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

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

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, Professionals and patients have patients inexperienced complementary knowledge and experiences Kane RL. Ageing Clin Experiment Res 2002

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Levels of health care for people with chronic disease

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Chronic Disease Management and Shared Care Pr ofe ssi on al Se ca lf c re are

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos The Chronic Care Model (CCM) Wagner EH et al. Manag Care Q 1997;7:56-66

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

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

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%)

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

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Benefits of better chronic disease management

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Quality Plan for the Public Health Care System of Andalusia http://www.juntadeandalucia.es/salud

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

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

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

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

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos • Atención Primaria: longitudinalidad y continuidad – Fragilidad en infaestructuras, medios, y tiempo. – Eficaz en procesos con demanda programable. Fracaso en procesos con múltiples reagudizaciones, necesidades de atención domiciliaria, demanda no programable. • Atención Especializada: Basada en la asistencia al episodio agudo, tendencia a la atomización, “tecnocrática”. – Especialidades médicas: • Buenos resultados para mono-patologías con canales asistenciales definidos. • Fracaso para pacientes con múltiple comorbilidad, y difícil adscripción. – Medicina Interna “clásica”: • “Atrincherada” y aislada en el Hospital. • Escasa plasticidad y adaptabilidad a cambios asistenciales. • Divergencias entre intereses dentro del propio colectivo.

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 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

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos http://www.juntadeandalucia.es/salud

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Liaison nurses: • 309 professionals • 225,254 home visits in 2009

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Patient‘s School

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

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

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos People studied: 140,892 With retinopathy: 31,306

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Users: 14,720 Total SMS: 180,435 Vaccines Warnings Appointments Advices

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

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

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

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Continuity of Patient Care Chronic diseases: A Challenge for Healthcare

Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Proactive Healthcare System Effective Self-management Support

Foro calidad OPIMEC José Luis Rocha

by Observatorio de Prácticas Innovadoras en el Manejo de Enfermedades Crónicas Complejas (OPIMEC) on Jun 14, 2010

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