Systems approach toARF/RHDDr Christine ConnorsProgram LeaderChronic Conditions Strategy UnitNT Department Health & Families
Acute vs. chronic illnessperson feels sick person feels wellperson seeks care care is promptedlasts a short time lasts rest of lifehealth staff are experts” person is “expert”“tell” the person the advise abouttreatment treatment optionsWestern medicine highly Western medicineeffective has limitationsless responsibility self care promoted
Chronic conditions care Organised program approach population lists and disease registers recall systems Care plans standard clinical guidelines supportive information systems (medical records, computers)
Recall issues 4 weekly penicillin, GP & cardiology review process: txt, phone, letter, home visit Who gets recall: person, family What if DNA Supporting structures e.g. full moon, fast track prioritisation
Chronic conditions care Health service managerial support business planning staff orientation and training data collection and feedback including CQI dedicated time and resources
Access to necessary expertise clinical specialists Outreach knowledge transfer: guidelines, case conference Technical specialists Echocardiogram public health specialists RHD coordinators, health promotion, PH physicians, PCD educators
Models of care Group education Group consults Case conference Link cardiologist with person/family and known PHC team Phone or video Significant decisions can be discussed
Systems that support self care Promotion self/family management community awareness use of care plans to promote self care processes that promote self care support the education and behavioural change needs of patients Don’t undermine self care
Impact of CQI intervention on health centre systems Organisational influence 11 10 9 8 Integration 7 External links 6 5 4 3 2 1 0Clinical information system Self-management Clinical delivery system Decision support Round 3 Round 2 Round 1
What does the evidence tell us? What is the average compliance? short drug regimes 20-55% long term drugs 54% lifestyle, diet changes 50% variations between 30 - 78%
American consumer survey Nearly three out of every four American consumers report not always taking their prescription medicine as directed Almost half of those polled (49 percent) said they had forgotten to take a prescribed medicine Nearly one-third (31percent) had not filled a prescription they were given Nearly three out of 10 (29 percent) had stopped taking a medicine before the supply ran out Almost one-quarter (24 percent) had taken less than the recommended dosageTake As Directed: A Prescription Not Followed.” Research conducted by The Polling Company.™ National
Extent of problemBetween 12% and 20% of patients take other people’smedicinesIn developed countries adherence among patients withchronic conditions averages only 50%1/3 patients fully comply with recommended treatment, 1/3sometimes comply and 1/3 never complyThe World Health Organization reports that only about43% of patients in developed nations take their medicinesas prescribed to treat asthma and between 40% and 70%follow the doctor’s orders to treat depressionEnhancing prescription medicine adherence 2007 by National Council on Patient Information and Education.
What effects compliance? Determinants features of therapeutic regime complexity, duration, behaviour change features of therapeutic source clinic, hospital, waiting times features of interaction level of supervision, contact, patient satisfaction socio behavioural features of patient patient perceptions, family support, history of compliance
Non compliance in chronic disease Patient and health professional working toward different goals Patients can become frustrated and dissatisfied if they feel that they are being judged and blamed for their inability or unwillingness to achieve medical goals When patients are viewed as collaborators who establish their own goals, motivation is intrinsic Concordance: mutually agreed goalsImproving Patient Adherence AM Delamater Clin. Diabetes 2006;24:71-77.
Strategies to improve compliance education health promotion, patient counselling, written instructions behavioural simplify regimes, reminders, serum monitoring, supervision, free medication, improved clinic access combination of both behavioural and combination strategies more effective than education alone
Communicating effectively Demonstrate respect and caring Talk to patients directly about the need for adherence Ask patients about their medicine taking habits and health beliefs Obtain agreement from the patient on the specifics of the medication regimen, including the medical treatment goals Communicate the benefits and risks of treatment in an understandable way Ask about and help resolve patient concerns upfront so they do not become hidden reasons for non-adherence.Krueger, KP, Felkey, BG, Berger, BA Improving Adherence and Persistence: A Review and Assessment of Interventions andDescription of Steps Toward a National Adherence Initiative. Journal of the American Pharmacists Association. 2003. Vol 43: 6
Cochrane systematic review 2008 keeping patients in care is arguably the most important adherence intervention at present the most important single intervention … is recalling patients who miss appointments…Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2.