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Missala, Isabelle - Chronic Care Management. Berlin Stroke Alliance (BSA) Charité
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Missala, Isabelle - Chronic Care Management. Berlin Stroke Alliance (BSA) Charité


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Track 4: Sostenibilidad de los sistemas sanitarios …

Track 4: Sostenibilidad de los sistemas sanitarios
4.2. Gestión de la cronicidad

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  • 1. Chronic Care Management MIHealth Congress 24.05.2012 Berlin Stroke Alliance (BSA) Isabelle M. MissalaUNIVERSITÄTSMEDIZIN BERLIN 1
  • 2. Charité – Universitätsmedizin Berlin Campus Buch Campus Virchow-Klinikum Campus Charité Mitte Campus Benjamin Franklin UNIVERSITÄTSMEDIZIN BERLIN 2
  • 3. Agenda WHO Definition „Chronic Diseases“ Key Facts Cardiovascular diseases STROKE Stroke Care Management: Berlin Stroke Alliance (BSA) UNIVERSITÄTSMEDIZIN BERLIN 3
  • 4. Definition WHOChronic diseases (CDs) are diseases of long duration andgenerally slow progressionare by far the leading cause of mortality in the world,representing 63% of all deathsOut of the 36 million people who died from chronic disease in2008• 9 million were < 60 years• 90% of these premature deaths occurred in low- and middle-income countriesExamples of chronic diseases:Coronary heart disease, stroke, cancer, chronic respiratorydiseases and diabetes UNIVERSITÄTSMEDIZIN BERLIN 4
  • 5. Key Facts Cardiovascular DiseasesCVD• CVDs are the number one cause of death globally:  More people die annually from CVDs than from any other cause.• An estimated 17.3 million people died from CVDs in 2008, representing30% of all global deaths. Of these deaths, an estimated 7.3 million weredue to coronary heart disease and 6.2 million were due to stroke.• Low- and middle-income countries are disproportionally affected:over 80% of CVD deaths take place in low- and middle-income countriesand occur almost equally in men and women.• By 2030, almost 23.6 million people will die from CVDs, mainly fromheart disease and stroke. These are projected to remain the single leadingcauses of death. UNIVERSITÄTSMEDIZIN BERLIN WHO Fact sheet N°317 September 2011 5
  • 6. CVD Disease Clinical Pictures• UNIVERSITÄTSMEDIZIN BERLIN 6
  • 7. Cardiovascular diseases –heterogenous group of disorder• Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and include:• coronary heart disease – disease of the blood vessels supplying the heart muscle• cerebrovascular disease - disease of the blood vessels supplying the brain• peripheral arterial disease – disease of blood vessels supplying the arms and legs• rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria• congenital heart disease - malformations of heart structure existing at birth• deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs. UNIVERSITÄTSMEDIZIN BERLIN 7
  • 8. Stroke Epidemiology Germany Men Women TotalFirst strokes 88 000 108 000 196 000Recurrent 30 000 36 000 66 000strokesTotal 118 000 144 000 262 000*based on data of the Erlangen Stroke register (2008) UNIVERSITÄTSMEDIZIN BERLIN 8
  • 9. Impact of Stroke• Third common cause of death (8%)• Cause of death 63.000/a (2008), regression!• Main cause of severe disability of the adult• Age of predisposition:60.-70. life year, half of the stroke patients are more than 73years old UNIVERSITÄTSMEDIZIN BERLIN 9
  • 10. The Berlin StrokeAlliance (BSA)2008–2012
  • 11. Aims• The BSA is an association of caregivers of stroke or TIA patients in Berlin and Brandenburg. The BSA was founded on the 26th of June 2008.• The purpose of the BSA is to:a. improve the care and outcome of patients with stroke or TIA (transistory ischemic attack)b. promote patient-based research projects UNIVERSITÄTSMEDIZIN BERLIN 11
  • 12. The BSA network• 48 full members• 4 associate members• in the field of:• Acute care,• Rehabilitation care,• Aftercare. UNIVERSITÄTSMEDIZIN BERLIN 12
  • 13. Project fields of the BSA Education &Training Research Coun selling Quality managementUNIVERSITÄTSMEDIZIN BERLIN 13
  • 14. Working AreasI) Improvement of Counselling of stroke patients and their relatives.II) Improvement of Education and Training in the field of „Stroke“ for various occupational groups involved in stroke - treatment.III) Coordination of Data Collection in the field of „stroke “.IV) Conduction of high-quality patient - based trials.V) Development of a coordinated chain of health care providers for stroke patients in Berlin (and Brandenburg). UNIVERSITÄTSMEDIZIN BERLIN 14
  • 15. Working GroupsI) AG Social ServicesII) AG Education and TrainingIII) AG Transfer ProcessesIV) AG Core Data Set RehabilitationV) AG AftercareVI) AG Longterm Management UNIVERSITÄTSMEDIZIN BERLIN 15
  • 16. AG Social ServicesAims:Multidisciplinary Transfer Sheet at the interface betweenRehabilitation > AftercareHighlights:Transfer Sheet, existing rules of procedures and prove ofdata protection of the transfer sheet UNIVERSITÄTSMEDIZIN BERLIN 16
  • 17. AG Education and TrainingAims:Development of a stroke specific educational program carried out by theBSA membersHighlights:4 established Curricula of the working group:• Medical Curriculum (Ø 16 participant)• Curriculum of healthcare professionals (Ø 40 participant)• Curriculum skills (28 participant)• Information meeting for patients and their relatives (Ø 18 participant)• increasing number of participant• evaluation „good“ and „very good“• Basic lesson „Stroke Nursing Expert“ for Nurses starts in 2012 • – UNIVERSITÄTSMEDIZIN BERLIN 17
  • 18. AG Transfer ProcessesAims:• Development of the Transfer form „Application of early rehabilitation and application for covering the costs “• IT-Support of Transfer (Webportal) between acute and rehabilitation care clinics.Highlights:• Form was developed and voted. UNIVERSITÄTSMEDIZIN BERLIN 18
  • 19. AG Core Data Set RehabilitationAims:Development of quality indicator (QIs) of post-strokerehabilitationHighlights:• Definition of a final indicator set of 18 QIs• Implementation 2012 UNIVERSITÄTSMEDIZIN BERLIN 19
  • 20. AG AftercareAims:Improvement of outpatient care (after inpatient care)Highlights:• Information packet for patients and relatives (hand-over to all BSA-members)• Implementation of a web-based database „Stroke-Pilot“ of stroke-care and additional support offers• Designation of a stroke-representative in all BSA- Member institutions UNIVERSITÄTSMEDIZIN BERLIN 20
  • 21. AG Longterm - ManagementAims:• Improved transparency and network of structure elements of outpatient management• Cooperation with stroke-specific quality circle programs• Development of a scientific-based concept of improvement of stroke patients longterm management in an outpatient setting• Early involvement of health insurrancesPilot-project Concept:• „University Outpatient Department of Management of stroke – longterm - results“• Promote networking of existing structures, evaluate ongoing activities UNIVERSITÄTSMEDIZIN BERLIN 21
  • 22. Servicepoint Stroke• Central Consulting Center for Stroke Patients and Relatives• Internet: UNIVERSITÄTSMEDIZIN BERLIN 22
  • 23. Servicepoint Stroke Servicepoint Stroke Consulting byInformation Stroke Support in care Information and Counseller managament MeetingsCounselling and BSA system partners Target Group:Stroke patients of all ages with and without need for assistance, relatives and those interested in the topic UNIVERSITÄTSMEDIZIN BERLIN 23
  • 24. Better Understanding, More effective treatment.UNIVERSITÄTSMEDIZIN BERLIN 24
  • 25. Thanks for your AttentionFor more information please UNIVERSITÄTSMEDIZIN BERLIN 25