Chronic disease management in Andalusia region, Spain

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  • 1. i Chronic Disease 1: Quick facts 2: Approaches 3: Results 4: Models 5: SWOT 6: Andalusia 7: OPIMEC 8: Future challenges
  • 2. 1 Chronic Disease 1: Quick facts
  • 3. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosChronic diseases are diseases of long duration andgenerally slow progression. Chronic diseases, such asheart disease, stroke, cancer, chronic respiratorydiseases and diabetes, are by far the leading cause ofmortality in the world, representing 60% of all deaths.Out of the 35 million people who died from chronicdisease in 2005, half were under 70 and half werewomen. http://www.euro/who/int
  • 4. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos“Health care systems world wide are faced with the challenge ofresponding to the needs of people with chronic medical conditions such as diabetes, heart failure and mental illness” http://www.euro/who/int
  • 5. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíoshttp://www.natpact.nhs.uk
  • 6. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíoshttp://www.albertahealthservices.ca
  • 7. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíoshttp://www.natpact.nhs.uk
  • 8. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosNational Health Survey: 18 million people report a Chronic diseaseNational 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
  • 9. 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 Cancerhttp://www.ine.es/inebase/cgi/axi
  • 10. 2 Chronic Disease 1: Quick facts 2: Approaches
  • 11. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíoshttp://www.euro/who/int http://www.paho.org
  • 12. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 13. 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/
  • 14. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 15. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 16. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíoshttp://www.euro.who.int/__data/assets/pdf_file/0008/96632/E93736.pdfhttp://www.euro.who.int/__data/assets/pdf_file/0006/96468/E91878.pdf
  • 17. 3 Chronic Disease 1: Quick facts 2: Approaches 3: Results
  • 18. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosCastlefields Health CentreCardiac 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
  • 19. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosCastlefields Health CentreHBA1c 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
  • 20. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosPatients 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
  • 21. 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 2007Improves appropriate referrals Slows progression to ESRN
  • 22. 4 Chronic Disease 1: Quick facts 2: Approaches 3: Results 4: Models
  • 23. 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 19thcentury notion of illness as a disruption of the normal state produced by a foreignpresence or external trauma, e.g. infection or injury…. Under this model of acute care isthat which directly addresses the threat…. In fact, modern epidemiology shows that theprevalent health problems of today (defined both in terms of costs and health impact)revolve around chronic illness” Acute disease Chronic diseaseOnset Abrupt Generally gradual and often insidiousDuration Limited Lengthy and indefiniteCause Usually single Usually multiple and changes over timeDiagnosis and prognosis Usually accurate Often uncertainTechnological intervention Usually effective Often indecisive; adverse effects commonOutcome Cure possible No cureUncertainty Minimal PervasiveKnowledge Professionals knowledgeable,  Professionals and patients have  patients inexperienced complementary knowledge and experiences Kane RL. Ageing Clin Experiment Res 2002
  • 24. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 25. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosLevels of health care for people with chronic disease
  • 26. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos • Over 80% of all medical symptomsProfessional 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 systemsSelf-Care educate, equip, and empower the true primary care providers… patients? 80%
  • 27. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosChronic Disease Management and Shared Care Pr ofe ssi on al Se ca lf c re are
  • 28. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 29. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosCore elements of the continuum of chronic disease prevention and care
  • 30. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosThe Chronic Care Model (CCM)Wagner EH et al. Manag Care Q 1997;7:56-66
  • 31. 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
  • 32. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 33. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 34. 5 Chronic Disease 1: Quick facts 2: Approaches 3: Results 4: Models 5: SWOT
  • 35. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosCDM Results from Physician Survey• 82% agreed that CDM tools would be helpfulto them in their practices• Only 24% respondents are currently involvedin chronic disease initiatives or programs• Physicians identified diabetes mellitus (74%)as the top candidate for CDM followed byhypertension (49%) and congestive hearthfailure (47%)
  • 36. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosBarriers 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
  • 37. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosLikely benefits of better chronic disease management Increased DecreasedControl of their own  Complications from their condition chronic diseaseFeeling of well being Unnecessary hospital  admissionsAbility to cope day to day Sense of powerlessness
  • 38. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosBenefits of better chronic disease management
  • 39. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 40. 6 Chronic Disease 1: Quick facts 2: Approaches 3: Results 4: Models 5: SWOT 6: Andalusia
  • 41. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosQuality Plan for the Public Health Care System of Andalusia http://www.juntadeandalucia.es/salud
  • 42. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos
  • 43. 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, acutecare and community care allowing for integration & management of carecloser to the citizen. In essence, provide the right care at the right timeto with the right provider, first time and every time”
  • 44. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosIntegrated Care Processes:Basis and Key elementsA 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 measurementsKey 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
  • 45. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos IDEF Methodology (Integrated definition for Function Modeling) ProcessSub-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
  • 46. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosHospitalizedpatients:Only 15% have asingle definedmedical problemAverage ofcomorbidity inelderly people(>65): 6,4 chronicdiseases
  • 47. 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, FREQUENTUNPLANNED READMISSIONS, HIGHLY INTENSIVE USER OF SERVICES THAT SHOWS THE UNSATISFACTORY MODEL OF CARE WE ARE OFFERING TO THESE PATIENTS
  • 48. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Key elements of Clinical ManagementA 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 Human resources Key Leadership Strategy Processes Satisfaction Results Resources & alliances Agents Results
  • 49. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosClinical Management RoadmapIdentify 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 systemSet an Improvement Plan with concrete objectivesCapacity to assume autonomy in decision making The Clinical Management Agreement
  • 50. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíoshttp://www.juntadeandalucia.es/salud
  • 51. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosLiaison nurses:• 309 professionals• 225,254 home visits in 2009
  • 52. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosAndalusian Plan forsupporting Familycaregivers:• 118,162 caregivers• 85% women• Average age 60 years old• 60% of cases singlecaregiver
  • 53. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosPatient‘s School
  • 54. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosBMJ, 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
  • 55. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosHeath 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
  • 56. 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 listsHealth RespondsInformation and Services Centre 20,000 Information dailyTelephoneappointment 100,000 daily Electronic prescription Virtual Office (InterS@S)
  • 57. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos People studied: 140,892 With retinopathy: 31,306
  • 58. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Users: 14,720 Total SMS: 180,435Vaccines Warnings Appointments Advices
  • 59. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosTransparency . 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 advicesInformation on Quality in Discharge telephone surveyHealth Centres AIDS, Tobacco, bird flu...Expectations bank SMS services Healthcare Information Health AdvicesCollection of Expectationsto promote participation e-Administration Living wills Smart card 24 health andalusia hr Individual assessment andand information information on Health
  • 60. Health Care Information andManagement Integrated System
  • 61. 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-06GP consultations before and after electronic prescription
  • 62. 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 schoolMulti-channel eHR information QualityRehabilitation certification plan e- Shared Prescription on-line incentives HTA Palliative care plan
  • 63. 7 Chronic Disease 1: Quick facts 2: Approaches 3: Results 4: Models 5: SWOT 6: Andalusia 7: OPIMEC
  • 64. 8 Chronic Disease 1: Quick facts 2: Approaches 3: Results 4: Models 5: SWOT 6: Andalusia 7: OPIMEC 8: Future challenges
  • 65. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíosContinuity of Patient CareChronic diseases:A Challenge for Healthcare
  • 66. Calidad de la atención a personas con múltiples enfermedades crónicas: nuevas oportunidades y desafíos Proactive Healthcare SystemEffectiveSelf-managementSupport