Implementing The Chronic Disease Management Framework - Shared Care - M Goulbourne - 29 Oct07


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Implementing the Chronic Disease Prevention Management Framework

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Implementing The Chronic Disease Management Framework - Shared Care - M Goulbourne - 29 Oct07

  1. 1. Implementing the Chronic Disease Prevention and Management Framework Moving from Operational Independence to Shared Care Michelle Goulbourne Global Perspectives on Chronic Disease Prevention and Management 2007 Conference Calgary, Alberta October 29, 2007
  2. 2. DISCLOSURE: I have no real or potential conflict to disclose.
  3. 3. Overview  Chronic Disease in the Canadian Context  Implementing the Chronic Disease Prevention and Management Framework in Canada  Regionalization  Discontinuities in Care  Impact on Performance  Implementation Experiences  Current State  Future State  The Road Towards Shared Care  Conceptual Model  Operational Model  Innovations Across Canada
  4. 4. Chronic Disease in the Canadian Context  In Canada chronic disease is a major Percent of adults with at least cause of death and disability. one of six chronic conditions*  The leading four preventable diseases cardiovascular, cancer, respiratory and diabetes, cost an estimated 45 billion dollars annually.  Two out of three adult Canadians have one or more of the major risk factors associated with a preventable chronic disease. (MOHLTC 2007) *Hypertension, heart disease, diabetes, arthritis, lung problems, and depression 2004 Commonwealth Fund International Health Policy Survey
  5. 5. Chronic Disease Prevention and Management Framework Goals  Nationally, Chronic Disease Prevention Management policy frameworks have been based on the Chronic Care Model developed by the Group Health McColl Institute for Healthcare Innovation in Seattle (Wagner et al. 2001).  Expanded versions of this model have been adopted because of their focus on health promotion and a coordinated systems approach to disease prevention and management are thought to provide important opportunities for: 1. Reducing care discontinuities 2. Increasing prevention behaviors 3. Improving population health 4. Reducing cost  Implementing the CDPM framework for such long lasting sustainable improvements is a challenge that requires a comprehensive system-wide, multi-leveled approach to change.
  6. 6. Regional Deployment of the CDPM Framework Regional deployment of the CDPM framework requires that within each region, local health care organizations:  Make systematic efforts to improve prevention and management of chronic disease.  Engage in delivery system design with a focus on prevention, improved access, continuity of care and flow through the system.  Facilitate personal skills and self-management support among the population by empowering individuals to build skills for healthy living and coping with disease.  Develop healthy public policy and supportive environments by creating and implementing policies that will improve individual and population health and address inequities. (MOHLTC 2007)
  7. 7. Implementing the CDPM Framework Literatures on strategy and organizational improvement suggest that we are not so good at implementing what we design or at developing the new capabilities the organization needs to survive and thrive – hence the need to become better at designing and implementing organizations that can carry out our purposes and provide settings where we can develop and thrive (Mohrman 2007).
  8. 8. Voices From The Field – Structural Issues  This CDPM framework, while insightful, shares no concrete information organizations can draw upon which shows them how they can build bridges to integrate organizational silos. “Chronic disease programs in state public health agencies across the United States are increasingly taking action to integrate activities across single-disease program lines. The perceived benefits of program integration are the motivating force behind these actions, but there is little documentation about how to integrate programs, what the benefits are to program integration, and what barriers exist (Yach et al. 2004, p. 2616).”
  9. 9. Voices From The Field – Process Issues  Implementation is described as being a difficult process. “Although the evidence base for some of these elements is incomplete, it is clearly a comprehensive and promising way to conceptualize a path to better care for people with chronic conditions. The problem is that we have no complete examples of an implemented CCM and no specifics about the best care changes to make or the most effective change process to use for implementing them…there is little or no information about the relationship between the presence of CCM elements and indicators of care quality (Solberg et al. 2006, p.311).”
  10. 10. Voices From The Field – Governance Issues The Reality: Divergent Values and Independent Action When organizations have been tasked with  Individual agencies may demonstrate territoriality and moving from single perceive a “loss of glory” (reluctance to share credit for achievements). disease to multiple chronic disease  Resource costs involved in creating partnerships inhibit frameworks in the collaboration. Fear that collaborations may impact on absence of a central independent fundraising activities. coordinating structure,  Problems integrating programs as each program may be they do not always governed by different policies, service terms and day-to respond to to-day operations - creating a “silo effect”. environmental  Difficulties maintaining smaller or underfunded programs uncertainty by engaging when they are integrated with established fully funded in collaborations. programs. (Robinson, Farmer, Elliot and Eyles 2007)
  11. 11. Summary of CDPM Implementation Issues  Governance  Leadership to help build and support inter-organizational bridges.  Structure  Complete examples about implemented CDPM frameworks  Evidence to support all parts of the framework  Best, most effective, care changes  Relationship between CDPM elements and quality indicators  Process  How to integrate programs and services across diseases  How to build bridges across organizational silos
  12. 12. Regionalization Across Canada, provincial efforts have paralleled global approaches in trying to deal with health system uncertainty by establishing regional care delivery organizations to create a more integrated, coordinated and patient oriented healthcare delivery system.
  13. 13. Healthcare Regionalization in Canada  In Canada Regional Health Authorities (RHA‟s) exist as autonomous organizations.  Relationships with health care providers are characterized by accountability agreements.  Are responsible for healthcare administration, planning and coordination within specific geographic regions.  Have appointed or elected boards and are responsible for the funding and delivery of community and institutional programs and services such as CDPM within their regions (Kirby 2002).  Governance models under which provincial RHAs operate varies across provinces.  Within each province, the level of centralization may have implications for CDPM activities and performance outcomes.
  14. 14. Incomplete Integration and Coordination  Despite sharing similar objectives, provincial health system transformations have produced RHAs that differ in size, structure, scope of responsibility and accountabilities .  While all RHAs manage hospital services, only some RHAs oversee laboratory services, long-term care, home care and a variety of other services.  No provincial authority contracts physician services, manage prescription drug programs or cancer services.  That these important care partners remain under the jurisdiction of provincial and territorial portfolios has implications for provision of integrated service delivery and coordinated CDPM care in the community.  Considerable local level variation exists in the way CDPM is implemented and the levels of success attained.
  15. 15. Results  Discontinuities in CDPM CDPM progress is hampered by care discontinuities associated with poor system integration and coordination. 1. Gaps in governance impede system capability to develop integrative policies and local level partnerships across hospitals, physician and community health stakeholders that will improve access to care, increase quality and health service delivery. 2. Lack of technological integration results in a loss of information about patient and family characteristics and histories. 3. Quality gaps in service integration and coordination remove opportunities for communicative interactions and knowledge transfer between patients, families and specific providers. The impact of these discontinuities is evident in our performance on global quality measures.
  16. 16. Performance • Overall Ranking • Information Technology • Disease Management • Physician Integration
  17. 17. Country Rankings Overall Performance Ranking* 1.0-2.66 2.67-4.33 4.34-6.0 NEW UNITED UNITED SICKER ADULTS AUSTRALIA CANADA GERMANY ZEALAND KINGDOM STATES OVERALL RANKING (2007) 3.5 5 2 3.5 1 6 Quality Care 4 6 2.5 2.5 1 5 Right Care 5 6 3 4 2 1 Safe Care 4 5 1 3 2 6 Coordinated Care 3 6 4 2 1 5 Patient-Centered Care 3 6 2 1 4 5 Access 3 5 1 2 4 6 Efficiency 4 5 3 2 1 6 Equity 2 5 4 3 1 6 Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6 Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102 * 2003 Data Source: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health P olicy Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard.
  18. 18. Technology
  19. 19. Public Investment per Capita in Health Information Technology (HIT) as of 2005 $192.79 $200 $150 $100 $50 $31.85 $21.20 $4.93 $0.43 $0 United Canada Germany Australia United Kingdom States Source: The Commonwealth Fund, calculated from Anderson, G.F., Frogner, B., Johns, R.A., and Reinhardt, U. “Health Care Spending and Use of Information Technology in OECD Countries,” Health Affairs, 2006.
  20. 20. Primary Care Doctors Use of Electronic Patient Medical Records, 2006 Percent of physicians 98 100 92 89 79 75 50 42 28 23 25 0 NET NZ UK AUS GER US CAN Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
  21. 21. Primary Care Practices with Advanced Information Capacity, 2006 Percent reporting 7 or more out of 14 functions* 100 87 83 75 72 59 50 32 25 19 8 0 NZ UK AUS NET GER US CAN *Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care. Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
  22. 22. Practice Use of Electronic Technology, 2006 Percent reporting AUS CAN GER NET NZ UK US routine use of: Electronic ordering 65 8 27 5 62 20 22 of tests Electronic prescribing of 81 11 59 85 78 55 20 medication Electronic access to 76 27 34 78 90 84 48 patients‟ test results Electronic access to patients‟ hospital 12 15 7 11 44 19 40 records Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
  23. 23. Prevention
  24. 24. Patient Reports on Reminders for Preventive Care, 2004 Percent of adults receiving preventive care reminders 75 49 50 50 44 37 38 25 0 AUS CAN NZ UK US 2004 Commonwealth Fund International Health Policy Survey
  25. 25. Physicians Reporting Routinely Sending Patients Reminder Preventive/Follow-Up Care Notice, 2006 Percent of physicians Yes, using a manual system Yes, using a computerized system 100 5 14 75 18 16 50 93 24 83 65 61 32 25 20 28 18 0 8 AUS CAN GER NET NZ UK US Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
  26. 26. Disease Management
  27. 27. Sicker Adults Given Self-Management Plan, 2005 Percent of sicker adults with chronic conditions* whose doctor gave plan to manage care at home 100 65 58 56 50 50 45 37 0 CAN US NZ AUS UK GER * Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma, emphysema, etc.), or depression. Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 27
  28. 28. Received Recommended Care for Chronic Condition, Sicker Adults, 2005 Percent received AUS CAN GER NZ UK US recommended care: Hypertension* 78 85 91 77 72 85 Diabetes** 41 38 55 40 58 56 * Blood pressure and cholesterol checked. ** Hemoglobin A1c and cholesterol checked, and feet and eyes examined. 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults
  29. 29. Physician Integration
  30. 30. Doctors‟ Reports of Care Coordination Problems, 2006 Percent saying their patients “often/ sometimes” AUS CAN GER NET NZ UK US experienced: Records or clinical information not available at time of 28 42 11 16 28 36 40 appointment Tests/procedures repeated 10 20 5 7 14 27 16 because findings unavailable Problems because care was not well coordinated across 39 46 22 47 49 65 37 sites/providers Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
  31. 31. Percent of Doctors Reporting Practice Is Well Prepared to Care for Chronic Diseases, 2006 Percent of physicians reporting “well AUS CAN GER NET NZ UK US prepared”: Patients with multiple 69 55 93 75 67 76 68 chronic diseases Patients with mental 50 40 70 65 48 55 37 health problems Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
  32. 32. We must do better. We can do better.
  33. 33. Implementation Experiences - Lessons Learned Successful Implementation - Prerequisites Barriers to Successful Implementations  Organizations in the health care  Absence of integrative governance community recognize that the and policy successful implementation of CDPM initiatives across providers may  Links all stakeholders groups. require  Administrative and clinical  Integrative governance accountabilities (Goulbourne 2007).  Local leadership  Deployment of chronic disease care  Cross-disease planning models in community settings suggest  Strategy that organizations need help with:  Multi-level partnerships  the strategic operationalization of  Knowledge sharing integration dimensions ,  Goal sharing  the relational coordination of  Information technology process factors (Robinson et al 2007;  Funding (Calnan et al. 2006, Robinson et al. Solberg et al 2006; Yach et al. 2004). 2007, Solberg et al. 2006, Wensing 2006).
  34. 34. Conceptual Model The complex sustainable integrated care delivery system solutions we seek require the implementation of „multisectoral, multidisciplinary and multicomponent’ initiatives. „Synergy, as it is manifested in the thoughts, relationships and actions within the healthcare community, reflects the one aspect of collaboration that gives partnerships that are able to achieve it a unique competitive advantage.‟ (Lasker et al. 2001)
  35. 35. Conceptual Model for CDPM Implementation (Goulbourne 2007) Shared goals, a synchrony of efforts and a synergy of effects. Vertical Integration of Structures Horizontal Integration of Knowledge, Differentiation of Tasks and Services
  36. 36. Operational Model A recent structured review of health care organizational interventions revealed that benefits to clinical performance, patient outcomes and cost reductions are empirically associated with transformations that include the revision of professional roles (increased medical roles to nurses and a widened scope of practice for pharmacists) and the use of computer systems for knowledge management (Wensing et al. 2006).
  37. 37. Operational Model for CDPM – A Focus on Asthma (Goulbourne 2007)
  38. 38. Shared Care Shared care’ is the term that describes increasing the ability of…primary care services, particularly GPs and pharmacists, to work more effectively… The term shared care is used to describe the joint provision of care, not necessarily in the same place or at the same time, by members of the primary care team and of a specialist team. Shared care schemes generally focus on diabetes, asthma and antenatal care, but several other conditions such as inflammatory bowel disease and hypertension might benefit from components of the shared care approach. Priority Areas: First round Evaluation of Shared Schemes (Department of Health 2003) Z/Primaryandsecondarycareinterface/DH_4015532
  39. 39. Governance, Networks and Synergy Governance is commonly recognized as  Interior Health – Regional Health being an important component to Authority, British Columbia Chronic Disease Prevention Strategy collaboration and functioning partnerships.  Integrated Service Plan & Primary Care Collaborative The type of governance structure involved  PHC/CDM Director, Advisory Committee, Change Management Team in CDPM implementations is important.  Integration of clinical and community health Governance structures shape the nature and  Negotiated physician involvement and composition of the partnerships, mode of participation via an alternate payment model decision-making and impacts on the ways in  Link stakeholders and processes to provincial initiatives which partner perspectives, resources, skills  Translate provincial innovations to regional and knowledge are combined. and local levels Governance is said to have a “profound  Established Chronic Disease Health Improvement Networks (6) impact” of the level of synergy within the  Multiple disease orientation partnership (Lasker, Weiss and Miller 2001, Touati et al.  Interdisciplinary team 2007).  Patient education and self-management support (Ockenden and Cheema 2004)
  40. 40. Collaborative Care: Enhancing Clinical Service Network Link Overlap Community based coalitions or sub- networks may provide space where organizations can develop levels of Acute Care Integrative synergy, exchange knowledge and Technology work together to pursue shared goals. Stronger cooperative ties are more Patients Physicians likely to develop among small clusters of organizations than among multiple Shared Community Primary organizations in a broadly based Care Care Care network (Provan and Sebatstian 1998). (EMR) Pharmacists Nurses Family Health Teams enhancing the efficient use of health care resources. Extra-Mural Program, New Brunswick a provincial home health-care program Ambulatory which is supported by a multidisciplinary Care network of hospitals, health centres and programs involved in health promotion, education and the provision of comprehensive health care services. (Goulbourne 2007)
  41. 41. New Roles for Pharmacists in Primary Care and Community Care Settings  Fraser Health Authority – Medication Management New Roles and Collaborations Program, British Columbia Commenced in 2005 across Acute, Primary and  Pharmacist performs home visits to assess medication Community Health Care regimens Settings.  Target → Seniors recently discharged from hospitals and clients high risk for drug related problems (6 or Pharmacist deployed into new more medications) settings where their drug expertise  Make recommendations to alleviate problems is used to: (prescribing pre-measured blister-packed medications, or eliminating unnecessary medications)  Enhance patient medication  Pharmacists also perform academic detailing practices, physician prescribing and drug monitoring under treatment.  Grand River Hospital Corporation and New Vision Family Health Team, Kitchener Ontario Commenced in 2006  Enhance patient safety and  Pharmacist has a shared care role across acute (.5FTE) optimal outcomes. Reduce the cost and primary care (.5FTE) sectors of patient non-adherence  Pharmacist provides drug information to (readmissions), adverse drug events interdisciplinary clinical team and after surgical intervention care.  Collaborates in the development and deployment of chronic disease prevention and management programs
  42. 42. We are doing better. We will continue to do better.
  43. 43. References  Goulbourne M. (2007). “Chronic Disease Prevention and Management: Examining regional governance, network structures and outcomes.” (draft document)  Kirby, M. (2002). “The Health of Canadians: The Federal Role Final Report. “ Ottawa: The Standing Senate Committee on Social Affairs, Science and Technology.  Lasker Roz D., Weiss Elisa S., et al. (2001). "Partnership Synergy: A Practical Framework for Studying and Strengthening the Collaborative Advantage." The Millbank Quarterly 79(2): 179- 205.  Ministry of Health and Long Term Care. (2007). “Ontario‟s Chronic Disease Prevention and Management Framework : Work of a Steering Committee. Presentation by Meera Jain, February 2007, Grimsby Ontario.  Mohrman S.A. (2007). "Having Relevance and Impact: The Benefits of Integrating the Perspectives of Design Science and Organizational Development." The Journal of Applied Behavioral Science 43(1): 12-22.  Ockenden, G. and Cheema G. (2004) “Addressing the Need for Improvement. The IH Chronic Disease Management Plan 2004-2006”. Government of British Columbia.  Provan Keith G. and Sebastian J.G. (1998). “Networks within Networks: Service Link Overlap, Organizational Cliques, and Network Effectiveness." Academy of Management Journal 41(4): 453-463.
  44. 44. References Continued  Robinson Kerry, Farmer Tracy, et al. (2007). "From Heart Health Promotion to Chronic Disease Prevention: Contributions of the Canadian Heart Health Initiative." Preventing Chronic Disease: Public Health Research, Practice, and Policy 4(2): serial online.  Solberg Leif I., Crain Lauren A., et al. (2006). "Care Quality and Implementation of the Chronic Care Model: A Quantitative Study." Annals of Family Medicine 4(4): 310-316.  Touati Nassera, Roberge Daniele, et al. (2007). "Governance, Health Policy Implementation and the Added Value of Regionalization." healthcare Policy 2(3): 97-114.  Wagner E.H., Austin B.T., et al. (2001). "Improving chronic illness care: translating evidence into action." Health Affairs 20(6): 64-78.  Wensing Michel, Wollersheim Hub, et al. (2006). "Organizational interventions to implement improvements in patient care: a structured review of reviews." Implementation Science 1(2): online journal.  World Health Organization. (2005). WHO Global Forum on Chronic Disease Prevention and Control: Final report of the meeting convened in Ottawa, Canada 3-6 November 2004. N. D. a. M. H. Department of Chronic Diseases and Health Promotion, World Health Organization and the Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, WHO.  Yach Derek, Hawkes Corinna, et al. (2004). "The Global Burden of Chronic Diseases." Journal of the American Medical Association 291: 2616-2622.