A Strategy to Tackle the Challenge of Chronicity in the Basque Country


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Sufferers from chronic conditions tend to slip under the radar of the health system. this is
because for decades the system has been based upon the logic of rescue, of saving lives and
so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it
is necessary to complement this system with one which deals in terms of caring as well as
curing, one which offers continuity of care throughout a person’s life, with the added potential
of preventing unnecessary hospitalizations and thus reducing costs.

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A Strategy to Tackle the Challenge of Chronicity in the Basque Country

  1. 1. A Strategyto Tackle theChallengeof Chronicityin the BasqueCountryJuly 2010
  2. 2. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Foreword Sufferers from chronic conditions tend to slip under the radar of the health system. this is because for decades the system has been based upon the logic of rescue, of saving lives and so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it is necessary to complement this system with one which deals in terms of caring as well as curing, one which offers continuity of care throughout a person’s life, with the added potential of preventing unnecessary hospitalizations and thus reducing costs. in the forthcoming two decades 26% of all Basques, the baby boomers, will belong to the over 65 age group. for the first time our society must prepare itself for a situation in which those who, today, are aged 50 will have to care for their parents for longer than they have looked after their children. Without major changes in our social policies and in the concept we have of ageing, it will be impossible to face up to the challenges of the current social panorama. this document proposes what is to be done and the steps to be taken in order to achieve just that in the Basque country. Medicine and bioscience will bring new discoveries in the decades to come. Many of these will save lives and will be fundamental for chronic patients. however, there are two other significant areas which will change: healthcare to the same degree as biomedical progress and which will also save a great number of lives and which will also be essential for chronic patients. i refer to the advance in information technologies and the organization of services. the Strategy described in this text values these advances equally to those of the progresses in biomedicine, pointing out that bioscience alone is not enough to face the challenge of chronicity in our societies. the way the health care system is organized at the provider level will become more and more important as we move forward. it should become as important as the treatments it provides. furthermore, in managerial terms, it will not be possible to improve the system by focusing only on the internal performance of care organizations. the improvement in coordination between them is even more important. Primary care, hospitals and social services are interdependent. it is necessary for them to find more collaborative and better coordinated approaches. it is in this collaboration in which advances are to be found for chronic patients and in which wide margins for efficiency improvements can be identified which will enable the sustainability of the health system. to this end, it will be necessary to cease to manage structures and to learn to manage integrated health systems, especially on a local level. in the Basque country we have a public nhS type of health care system. All health care professionals are salaried in both primary health care and hospital care. the important lesson of the past years is that despite this apparently tidy vertically integrated system in management terms, at the provider level this system has not achieved integrated clinical care and continuity of care. Management integration at all levels does not guarantee clinical integration where we need it at the provider level. it is therefore necessary to do something different. this Strategy provides the context to do something different.
  3. 3. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrythe basic premise therefore is to avoid taking any policy decisions which might further fragmentcare and, rather, ensure we are developing local systems of care which offer continuity ofcare. consequently, the policy context in the Basque country will strive to build collaborationrather than competition and more concretely, what we propose is not a magic wand, but anorganized progression, activating many levers of change.investment is required in an information strategy and the technology to make it possible, it isnecessary to use new approaches to educate patients to manage their illness, to continue topromote evidenced-based medicine, and also to integrate primary care, hospital care andsocial care and to develop new professions which integrate care.iit is necessary to manage all these levers simultaneously. coordinated activation of all theselevers will provide the required set of tools with which to bring about the necessary change.they are presented here as strategic interventions which will enable us to meet the mostcomplex and important challenge of recent decades: that of organizing a health system worthyof the chronically ill, the most significant challenge of the 21st century.Although not in all cases, many of these new interventions will bring new efficiencies. theyshould all however and without exception provide better care and security for chronic patients.furthermore, many of our management and leadership concepts must change. none of thiswill be achieved with the kind of leadership we have known in the past. the complexity of thechange requires the development of a different leadership approach in the forthcoming decade.With the aim of reaching the necessary alignment between local and corporate level, we arecommitted to a better distribution of leadership, in which central management create theconditions to promote organization innovations which are inspired by local management andhealth professionals themselves. it is in this local arena in which the main innovations necessaryfor chronic patients will be found. rafael Bengoa Minister of Health and Consumer Affairs Basque Government 1
  4. 4. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country2
  5. 5. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryContentIntroduction 4The challenge and the opportunity presented by chronicity in the Basque Country 6 2.1 chronicity in the Basque country 7 2.2 the different needs of the chronically ill patient 13 2.3 reference and care intervention models for the chronically ill 14 2.4 What does the evidence say? 18The need for a system strategy 22The strategy for the Basque Country 26 4.1 Vision of the future 27 4.2 Policies 30 4.3 Strategic Projects 37Achieving change: Introduction strategy 60 Accepting complexity 61 top-Down and Bottom-up 62Index of tables and figures 66 tables 66 figures 67 Barring indications otherwise, this study is published under Creative Commons licence (BY) For further information and complete license: http://creativecommons.org/licenses/by/3.0/deed.en Photographs: ©M. Arrazola - EJ-GV (Unless otherwise indicated at the foot of the photo) Edited by Eusko Jaurlaritza – Basque Government – Department of Health and Consumer Affairs. Dep. Legal - BI-2345-2010 3
  6. 6. Introduction
  7. 7. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryWe often confuse interim short-term tactics with medium term strategies. the former canbe found in abundance, the latter are in short supply.this document provides a framework of action for the medium term transformation ofthe Basque health System. it is independent but complementary to the interim measuresand management policies that have been put in place due to the current economic crisis.While the interim measures attempt to reduce expenditure in the short term in order toensure sustainability, the final result of this Chronic Patients Strategy aims to outlinea new way of organizing care causing an impact on each and every aspect of the system(health results, satisfaction, patient and carer life quality, and sustainability). thus, thisstructural transformation goes beyond the current economic situation, requiring a longperiod (at least between 2 and 5 years) before achieving a substantial impact on thesystem.life expectancy for the Basque population has extended considerably in recent decadesand a significant parallel change has taken place in life styles. one consequence of thisis that the prevalence of people suffering from chronic illnesses is increasing to the extentthat the great majority of patients in our health system are suffering from one or morechronic illnesses.The response to the needs of people suffering from chronic illnesses has become theprincipal challenge faced by the Basque Health System (BHS). these pathologies havea multiple impact: they represent a considerable restraint on life-quality, productivity andthe functional state of people who suffer from them; they exert a strong influence onmorbidity and mortality rates; and they accelerate the increase in health and social costs,which compromises the medium term sustainability of the healthcare system.the path towards progress in this area requires a change in the existing conceptualframeworks, within which curing and caring, take place, and one which is clearly outlinedin the current health and social policies. The individuals and their environment, theirhealth and their needs have become the central focus of the System at the expenseof merely treating the illness.the existence of a higher number of chronic conditions in a person generally leads to agreater risk of incapacity and mortality, and within the chronic pathologies there are somewhich are notoriously disabling. this close relationship between chronic illnesses anddependence is the determining factor with regard to prioritizing and indentifying the mostsuitable health and social policies.in addition, chronicity implies a challenge to the quality of care provided, as the peoplewho suffer from chronic illnesses are more likely to receive less than optimum care andto suffer adverse pharmacological side-effects.furthermore, the challenge of chronicity requires proactive measures to combat the healthfactors which give rise to it in the first place. hence the importance of anticipation, settingup a framework of action which reduces its emergence and progression by means ofawareness and preventive actions.to summarize, chronicity is a in system terms global challenge and consequently requiresa systematic response. Beyond particular illnesses or specific groups of sufferers, it is achallenge which must take into account everything from the structural conditions andthe lifestyles which contribute to the increase of the pathologies in question to the socialand health requirements of the chronically ill patients and their carers: from the initialstages up until the care provided during the final phase of life, including all aspects ofcare, convalescence, and rehabilitation.This Strategy aims to improve the health and welfare of all people who are affectedby chronic illnesses, as well as to reduce both the level and the impact of chronicity. 5
  8. 8. The challengeand theopportunitypresented byChronicity inthe BasqueCountry
  9. 9. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country2 .1 T h e c h a l l e n g e a n d T h e o p p o r T u n i T y presenTed by chroniciT y in The basque counTrythe prevalence of chronic illnesses increases according to age groups in all cases, butconsiderably so for those aged over 65, diabetes and osteoarticular pathologies reflectingthe highest increases.in the majority of pathologies, an increase can also be observed in the prevalence amongthe over 85 age group, especially in the case of neurodegenerative dementias.comparing the most recent data (eScAV’07) with the prevalence data for chronic problemsincluded in the Basque country health Surveys from 1997 and 2002, it can be seenthat the percentage of chronic patients increases in the over 45 age group, which is ofparticular concern in the current context of population ageing, and, logically, an increasein the more advanced age groups is to be expected in the near future.According to the Basque health Survey carried out in 2007 (eScAV’07) 41.5% of men46.3% of women stated they were suffering from at least one chronic health problem.As can be seen in figure 1, the prevalence of chronic problems was higher in womenthan in men (with the exception of the under 17 age group) and this difference increasedwith age.Figure 1Prevalence of chronic problems according to age and sex 100 90 80 70 60% 50 40 30 20 Men 10 Women 0 <17 18-44 45-64 >65 Agefuente: elaboración a partir de eScAV 2007Similarly, among the elderly (over 65 years of age) it is not uncommon to find personswith multiple chronic pathologies. Patients with this profile run the risk of suffering somekind of disability or death. 7
  10. 10. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Figure 2 Distribution of the population aged over 65 according to the number of chronic problems 8,6 % 23,4 % None One 28,9 % Two Three or more 39,1 % Source: Data from eScAV 2007 in fact, the clinical data provide a clear vision of the number of chronic conditions according to patient age, as can be seen in figure 3. Figure 3 Distribution of patients according to the number of chronic illness by age 80% 70% 60% 50% 6+ illnesses % 40% 5 illnesses 30% 4 illnesses 20% 3 illnesses 10% 2 illnesses 0% 1 illnesses 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95+ Age Source osabide 20078
  11. 11. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrythis multimorbidity reflects conditions which are particularly representative, not leastwhen it constitutes a wide spectrum of chronic illnesses combined in different ways.Figure 4Main medical conditions appearing in patients with multimorbidity(3+ chronic illnesses) according to the primary care diagnosis70% 65%60%50% 39%40% 35%30% 23% 18%20% 13% 10% 9% 9%10% 5% 4% 0% n ia es s n ia C n a I re CC iti m sio i io O m em pa ilu t hr be h ss EP pe en st fa h al rt re ia isc A li t A ic ey ep er D er rv ac dn ypyp D Ce i H kiH rd Ca ic n ro ChSource osabide 2007from the comparison of the most recent data concerning the prevalence of chronicconditions (eScAV’07) with the data from the health Surveys in 1997 and 2002, it canbe observed that the percentage of chronic patients is increasing, above all in the moreadvanced age groups (figure 5). for example in the case of persons aged between 45and 64 in 2007, compared to the figure for 1997, there were almost 90,000 more peoplewho declared some kind of chronic ailment.Figure 5Change in the percentage of persons with chronic problems between 1997 and2007 according to their age 90 80 70 60 50% 40 1997 30 20 2000 10 2007 0 <17 18-44 45-64 >65 AgeSource: eScAV 9
  12. 12. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country in fact, a retrospective analysis of certain illnesses reveals that their prevalence is increasing at a considerable pace. Figure 6: Change in the prevalence of diabetes and cardiovascular disease in the Basque Country In 15 years the prevalence of chronicity in the Basque Country has increased notably throughout the region Percentage 1992 1997 2002 2007 4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0 Source: eScAV 1992, 1997, 2002, 2007 in order to provide a more detailed picture of chronicity in the Basque population a series of illnesses was selected according to the following criteria: • the principal diagnosed chronic illnesses (neoplasias were not included due to their special characteristics) • the main causes of mortality. the following figure outlines the number of chronic patients aged over 18 with each of these conditions, along with their prevalence according to the diagnoses in Primary care. it can be observed that the osteoarticular pathologies along with diabetes are the most common illnesses among the Basque population. Figure 7 Number (and prevalence) of chronic patients over the age of 18 suffering from the principal pathologies (according to diagnoses in Primary Care) Arterial Hypertension 172.820 (10,33%) Hypercholesterolemia 117.280 (7,01%) Osteoarticular Pathology 74.402 (4,45%) Diabetes 71.656 (4,28%) Asthma 34.154 (2,04%) Cardiovascular Diseases 33.246 (1,99%) Neurodegenerative Dementias 23.153 (1,38%) COPD 22.995 (1,37%) Obesity 18.469 (1,10%) Source: own data from osabide10
  13. 13. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country A more detailed analysis on the age distribution of these chronic pathologies indicates that the degree of prevalence is increasing, in almost all cases, considerably so from the age of 65, with the increase being especially notable in the osteoarticular pathologies (>13%) and diabetes, which reaches a prevalence level of above 12%. neurodegenerative dementias become particularly apparent from the age of 85 onwards. Figure 8 Prevalence of the principal pathologies by age groups (according to diagnoses in Primary Care) 25,00 20,00Prevalence (%) 25,00 10,00 18 a 44 5,00 45 a 64 65 or above 0,00 C s a r s ar la tia te hm O ul cu be EP en tic st as ia em A ar ov D eo D i rd st Ca O Source: own data from osabide 11
  14. 14. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country the study carried out by the Department of health in 2008 “the impact of different illnesses on the health of the Autonomous community of the Basque country” reveals that, among the selected illnesses, those with the greatest influence on mortality rates for men were the cardiovascular and ePoc diseases, which caused 16.4% and 6% respectively of all deaths. in the case of women, cardiovascular illnesses were also the major cause of deaths (17.3%), while diabetes was the second most dangerous (3%). on the other hand, in spite of not having such a high impact on mortality rates, osteoarticular pathologies are very relevant in as far as disability is concerned. the study estimated that out of all males suffering from a disability, 26.6% could be attributed to this kind of pathology. As for women, the influence of these illnesses on disabilities was even higher, with a prevalence of osteoarticular pathologies among disabled women of 45%. this situation of prevalence and increasing incidence of chronic pathologies is not a phenomena limited only to the Basque country, but one which is also taking place throughout Spain, with an expected annual increase, according to the prevalence data from the Patient Base of Decision resources, of approximately 1.2% in the number of type 2 diabetics among the Spanish population aged over 20, rising to affect some 7.7% of the population by the year 2016. this increase in prevalence also occurs, to a greater or lesser extent, in a great number of regions throughout the world, being, furthermore a tendency, which according to forecasts, will continue to increase, aggravating even further an epidemiological situation which is already very serious. Figure 9: Illustration of the forecast for chronic illnesses throughout the world – Example Diabetes A nivel mundial las enfermedades crónicas tienen las características de una pandemia en expansión. On a global level chronic illnesses bear the characteristics of a pandemic in expansion <4 4 to <8 8 to 14 >14 Forecast of the change in levels of diabetes on a global level(1) 2007 2025 Source International Diabetes Federation Source: international Diabetes federation: Diabetes Atlas12
  15. 15. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 2 . 2 d i F F e r e n T i a l n e e d s o F T h e c h r o n i c a l ly i l l paT i e n T Although chronic illness is defined by a standard list of defined pathologies, it does present a series of differential factors: long duration, slow and continuous progression, it decreases the quality of life of those affected, and frequently reflects a significant level of comorbidity. furthermore, it is a cause of premature death and has significant economic repercussions for families and society in general. for the purposes of analysis and the approach followed in this document the following list and characteristics have been used. Table 1: list (not exhaustive) of chronic illnesses and their characteristics Chronic illnesses are very widespread and have certain characteristics in commonPossible illnesses consideredchronic Common characteristics 1 They have multiple causes and complications Diabetes mellitus 2 They normally appear gradually, although they can appear Cardiovascular diseases suddenly and present acute states (Ischemic cardiomyopathy, cardiac insufficiency, cerebral 3 They emerge throughout the life cycle though they are more vascular illness) prevalent in the elderly Chronic respiratory diseases 4 They compromise the quality of life causing functional limitations (EPOC, asthma) and disability Osteoarticular diseases 5 They are long lasting and persistent and result in a gradual (rheumatoid arthritis and severe deterioration in health arthrosis) 6 They require long term medical care and attention Neurological diseases (epilepsy, 7 In spite of not being immediately life threatening they are the Parkinson’s disease, multiple most common cause of premature death sclerosis) 8 In some cases they are limited to non-contagious diseases, Mental illnesses (dementia, although more recently they have been included illnesses such as psychosis, depression)) AIDS or tuberculosis HIV/AIDS 9 Fortunately, a significant number of them can be prevented or Digestive diseases (chronic their appearance can be delayed, while in others, given the level cirrhosis and hepatopathy, of current communication, their progress can be slowed down ulcerative colitis, Crohn’s and their associated complications reduced disease) 10 The distribution of the conditions and causes that favour the Chronic renal diseases … development of these illnesses in a population is not uniform, being the less well-off sectors which present greater frequency. The growing accumulation of risk factors in these less well-off groups will continue to increase the gap in health results Source: health Study and research Services of the Department of health and consumer Affairs of the Basque government Beyond the specific chronic illness or combination of illnesses, the focus of these differences is the phenomena of chronicity and the factors involved since its outset, the treatment, be it preventive, curative, palliative, or rehabilitation, up until the final stages, with the chronic patient in the centre of the care pathway. this evolving social construct which we call chronicity encompasses patients with different diseases and at different levels of seriousness. With this in mind, the focus of this document is global and is not devoted solely to specific diseases. 13
  16. 16. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Whatever the particular illness, the most important factors in the interventions in chronic procedures are different to those for acute illnesses. 1. they require a complete diagnosis of the patient including their social situation and their role as opposed to a traditional diagnosis focussed on the illness and the acute symptoms. 2. Proactive, preventive (primary and secondary) and rehabilitation interventions are more important than a typically curative focus on the acute illness. 3. the patient and the carer play a much more important role in the successful outcome of the intervention with the need to change life styles and adhere to these over long periods in contrast to the traditionally passive role of the care receiver. 4. they require a coordinated approach to care with an “individual vision” at all levels of care (primary, specialized, medium stay, mental health, emergencies, social services, health at work, etc.) throughout the duration of the illness as opposed to a rapid and specialized action on the part of a limited number of specific departments. 5. the needs and priorities (medical but also emotional, social, material and even spiritual) of each patient are given more importance considering that we are often dealing with continual interventions over the remaining lifetime of an individual compared to a specific intervention which has a limited impact on a person’s quality of life in the mid-term. these differences in the focus of the interventions are such that the phenomena of chronicity requires a model of care different to that typically used for acute illnesses. 2.3 Fr aMeWorKs and care inTerVenTion M o d e l s F o r T h e c h r o n i c a l ly i l l currently there exists, at a global level, a broad base of highly developed theoretical models. in addition, in recent years, specific interventions have been outlined, the efficacy of which can be tested as they have been carried out in various health systems in different parts of the world. Specifically, in this section the main reference models have been included (ccM, iccc, kaiser Pyramid of care, the king’s fund Pyramid) along with some examples of interventions with scientific evidence. Probably, the outstanding international reference model for chronic patient care is the Chronic Care Model CCM developed by ed Wagner and by collaborators from the Maccoll institute for healthcare innovation in Seattle, in the uSA. in this model, care for chronic patients takes place on three overlapping levels: 1) the community with its policies and multiple public and privates resources; 2) the health system with its supplier organizations and insurance schemes; and 3) the interaction with the patient in the clinical practice.14
  17. 17. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryTable 2Adaptation of the care model for Chronic Patients in the Basque Country Health system Organization of health system Self- Design of Medical Decision Community, management provision information support Resources and system systems Policies Activated Proactive Informed Productive Health Patient Interactions Team Medical and functional resultsSource- Developed by ed Wagner and collaborators from the Maccoll institute for healthcare innovation. Adapted by o+berriBasque institute of health innovationthis framework identifies six essential elements which interact among themselves andwhich are key to achieving optimum care for chronic patients. these are:• organization of the healthcare system.• Strengthening of links with the community.• fostering and support for self-care.• Design of the care system.• Decision making support.• Developing clinical information systems.the final objective of the model is that active informed patients become the protagonistsof the medical encounter along with a team of proactive professionals with the requisitecapabilities and skills, all in pursuit of a high quality level of care, increased satisfactionand improved results.Standing out among the adaptations of the ccM is the model proposed by the Worldhealth organisation, known as “The Innovative Care for Chronic Conditions Framework(ICCC)”. 15
  18. 18. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Table 3 The Model of Innovative Care and Chronic Conditions (ICCC) Framework of Positive Policies Strengthening of alliances • Development and assignation of human resources • Policy integration • Support from the legislative framework • Guarantee of suitable financing • Leadership and support Health Organization Community Fostering continuity and coordination. Awareness and taking Prepared away stigma. Promoting quality through leadership and Promoting better results incentives. through leadership and en ity He team support. Organization and Ag mun alt s ts funding of the health hC Mobilization and coordi- care teams. m nation of resources. are Co Use of information Provision of complemen- d Mo systems. me tiv tary services. o Patient and ated r Support for self-care and Inf prevention. family Better results for chronic conditions Source: Who this model adds to the ccM a model health policy perspective of which the main ideas are the following: • Decision-taking based on evidence • focus on the health of the population • focus on prevention • emphasis on the quality of care and on system quality • flexibility/adaptability • integration, as the hard fractal core of the model Apart from the system models such as ccM and the iccc, the other type most frequently used is that which refers to population models, the focus of which is the population as a whole and its needs instead of those of the health care system. Standing out among these is the “Kaiser Pyramid” which identifies three levels of intervention depending on the level of complexity of the chronic patient. in posterior interpretations to the kaiser model the population aspect of promotion and prevention has been included. the main idea set out by the kaiser Pyramid is one of segmentation or stratification of the population according to its needs: in the patients with more complicated cases with frequent comorbidity an integral management of the case is required with the provision of fundamentally professional care. • high risk patients but whose cases are less complex as far as comorbidity is concerned receive a disease management approach which combines self-management and professional care. • the majority of chronic patients with conditions which are still incipient receive support for the self-management of their illness. • finally, the general population is the focus of promotion and prevention actions which aim to control the risk factors which might contribute to the development of chronic illnesses in individuals.16
  19. 19. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryTable 4Extended Kaiser Pyramid Professional care Patients with severe complications (5%) Case Self-care Management Illness High risk patients (15%) Management Chronic Self-management support patients (70-80%) Promotion and Prevention General PopulationSource: kaiser Permanent. Adaptedone of the most interesting adaptations of the kaiser Pyramid which has been put intopractice is the pyramid defined by the king’s fund in the united kingdom. in this adaptationwhat stands out is the combination of the health and the social vision as two integralparts of the care requires by a person. 17
  20. 20. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Table 5 Pyramid defined by King’s Fund in the United Kingdom Pyramid de ned by King’s Fund in the United Kingdom Adapt the service to the individual Social vision Health vision Support people Individuals with highly who have more needs at home; complex needs/morbidity; take them away from permanent residences Level 3 improve the care for chronic patients; Case separate them from acute care Management High quality support Higher risk patients; to carers at home Level 2 specific interventions Managing to combat the illness; early diagnosis the illness Appreciate people’s value; 70%-80% of individuals; investment in voluntary Level 1 health promotion; prevention services nutrition; exercise Self- Management Source: king’s fund (c.ham) 2 . 4 W h aT d o e s T h e e V i d e n c e s ay ? As well as conceptual frameworks of action, there have also been interventions in recent years which have offered scientific evidence of their effectiveness, revealing the possibility of improving results at different levels (health results, patient and carer satisfaction and quality of life, sustainability) by changing the way of managing chronic illnesses. nevertheless, the majority of these interventions have been carried out in particular health systems and their extension and adoption by other systems has been limited and difficult. this only underlines the complexity associated with the implementation of these interventions and the change in systems to the level required by the model. Among these interventions a significant number have shown improvements in patient and carer satisfaction levels (e.g. care coordination, case management, telemedicine). in relation to the results corresponding to health outcomes and efficiency improvements there are fewer specific examples with clear evidence (e.g. case management by nursing – Boyd/Boult). however, the systems which have given clear backing to these kinds of models (e.g. kaiser Permanente in the uSA, Jonkopping, in Sweden, various area health authorities in england, canada, new Zealand and Scotland) in general demonstrate better health outcome results than comparable institutions with a high level of efficiency. for the design of this Strategy for tackling the challenge of chronicity in the Basque country we have taken into consideration: • the reference of the models outlined above, as well as the interventions which have proven to be effective. • the collaboration of the international centres of excellence mentioned above, many of which were represented at the international congress organized in Bilbao (2nd-3rd June 2010) with the objective of contrasting and comparing their experiences with the strategic proposal designed for our situation.18
  21. 21. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country• the thorough national and international analyses of all the evidence relating to the management of chronic illnesses.We include below in the section “ the relationship with health Systems Sustainibility “ asummary of the most significant conclusions of these analyses1.it is important to highlight that the evidence in favour of the interventions indicated in thisStrategy is growing, indicating that there are numerous opportunities for the Basque healthSystem.indications are that investments in this line of action in general will be beneficial for patients,will be cost-effective, will reduce the number of hospital admissions, that they will improveefficiency and will reduce the mortality rate.The relationship with Health System sustainabilitythe basic notion resulting from these studies with regard to efficiency can be resumed asfollows:• it is necessary to organize a system which is able to deal with comorbidity and not merely to deal with one illness at a time, (35% of people aged over 80 suffer from two or more chronic illnesses).• the most significant potential benefits arise from the prevention of the unnecessary admission of complex patients into the hospital system.• the cases which activate a sole intervention (e.g. remote medical monitoring from home, or training patients for self-management) may not achieve the desired efficiency impact. to obtain efficiency improvements, it is necessary to systematically intervene, working several levers of change, using the models outlined above in an integrated and coordinated fashion.• economic results will appear in the mid term.• it is worth “noting down” the management interventions of chronic patients according to the predictions of high use (e.g. recent hospitalization, frequent use of emergency wards, certain medical indicators). By acting in this way, saving opportunities will be substantially enhanced.• individualized planning previous to admission and advice from multi-disciplinary teams guarantees substantial reductions in avoidable re-admissions, even in the absence of other interventions.• When patient groups are easily identifiable and classifiable, face-to-face interventions which combine education with clinical care including contact with primary care or hospital specialists, as well as remote electronic monitoring are considered worthwhile in efficiency terms. consequent reduction in use and expenditure tends to be positive.• intensive and individualized education combined with treatment is more effective with diabetic patients (with the exception of the elderly) and with asthmatic patients.• interventions based on opportunistic education during the patient-doctor interaction tends to be less effective compared to highly intensive educational interventions focussed on patient self-management.• interventions for the management of congestive cardiac failure and for the elderly with multiple conditions have proved to be the most fertile area for achieving health improvements and relevant economic savings.• Studies confirm an positive return on investment in congestive cardiac diseases, asthma, and with patients with multi-pathologies. the main saving would be in the fall in admissions and readmissions as well as in daily costs.1 Chronic Disease Management: Evidence of Predictable Savings; J. Meyer and B. Markham. 2008 19
  22. 22. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country • in asthmatic patients the saving is substantial due to the reduced use of the emergency services. • in chronically ill patients who were treated more intensively and individually, the fall in hospital admissions was from 21% to as high as 48%; with asthma patients in particular, the fall in admissions ranged between 11% and 60%. in diabetics hbA1c values dropped by 1% and hospital admissions fell from between 9% and 43%. Among elderly patients with multiple pathologies the fall in hospital admissions was from between 9% and 44 %. Although the evidence on the impact of the management of chronic care is heterogeneous and generalizations should be carefully evaluated, the overall analysis indicates that significant and foreseeable savings could be achieved. this data confirms the growing interest in this line of work to ensure the SuStAinABility of the Basque health System. therefore the new Strategy for the Basque health Service has been designed along these notions.20
  23. 23. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 21
  24. 24. The needfor aSystemStrategy
  25. 25. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country As has been discussed in the previous section, in the Basque country, chronic illnesses represent the dominant epidemiological situation of the country. it is estimated that they currently represent 80% of the interactions with the Basque health System and account for more than 77% of health expenditure. however, the basic characteristic of the current care model is reactive, in which the patients have an episodic relationship with the health system and this logic is not what chronic patients need. in fact the current System is designed and structured to comply with an epidemiological model focussed mainly on acute interventions which do not correspond to today’s needs. furthermore, there is a lack of integration between the health system and the other social resources associated with health, which, as has been seen, is of substantial importance for chronically ill patients. Table 6: The reactive nature of the current system The health system is still mainly reactive Population has not We do not have We do not have been stratified... case nurses... routine medical reminders... Care is fragmented... Patients are The patients who could not activated... be are not telemonitored Source: own elaboration the structural tendency towards the increasing relevance of chronic patients means that it is absolutely necessary to respond to their needs, both from the point of view of health results and in order to guarantee the sustainability of the system in a situation in which there is increasing pressure on expenditure. Based on the above (epidemiological challenge, chronic patient needs, international evidence….), this Strategy has been drawn up in order to adapt the Basque health System to the current demands and those of the future in areas of prevention and care for chronic illnesses. it is important to point out that this strategy is not a repudiation of the excellent management of acute illnesses, but one which complements the current acute organisation with the capacity to also respond adequately to the needs of chronic patients: 1. the challenge of chronicity goes beyond the illness and the symptoms, so the Strategy needs to broaden its vision of the individual: not only their biomedical situation but also their social and functional situation. 2. tackling chronicity also requires overcoming the conventional programmes of episodic treatmen. it is necessary to try and reduce the appearance and the adverse effects of chronic illness by means of a population approach in which prevention and health promotion are key elements.istockphoto - getty images 23
  26. 26. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 3. the patient and their carer cannot be passive elements in this strategy. they have a central role which requires training and an increased awareness beyond that of their traditionally passive role. 4. chronicity requires a holistic vision of the patient and an all-embracing and coordinated focus both from within the health system (primary, specialized, medium-stay, mental health, emergencies) and from beyond, embracing the institutions, Departments, Programmes and available technologies and infrastructures directly related to chronicity (social assistance, sport, health at work). 5. finally, chronicity requires that the range of available interventions is widened and adjusted to the needs and priorities of the patients in each of the phases of their illness (from the outset to the end of their lives, embracing convalescence and rehabilitation). this new strategic approach is supported by international trends and by the increasing evidence of the effectiveness of the interventions and models mentioned in the previous section, more in tune with the needs of chronic patients. All in all, the Strategy is presented as an opportunity for change in the model to one in which the agents involved participate in the establishment of a framework of action for an integral management of chronicity from the population perspective, building upon the existing capabilities of the system. the following table shows a series of emerging elements which complement the existing model in the interests of achieving the aforementioned change. Table 7 Towards a new model for the Basque Health System Current Elements Emerging Elements Accessibility face–to-face remote Product health services health value Architecture Supplier focussed citizen focussed of Service and of Quality of the System Management • continuous and • episodic coordinated Care Model • reactive • Proactive • hospital focussed • integrated • health • Accessibility Value Proposal • Prevention, cure, care • focussed on care and rehabilitation Source: osaberri24
  27. 27. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 25
  28. 28. The strategyfor theBasqueCountry
  29. 29. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country the strategy designed for the transformation of the Basque health System along the lines mentioned above is structured in the following way: • it is based on a medium term Vision, which defines and describes the desired future situation. • it describes the health care Policies for chronic patients as guidelines for the successful fulfilment of this vision. • finally, there is a series of Strategic Projects which contribute towards generating and implementing the change to make the policies and the vision a reality in each one of its dimensions. Table 8 Strategic Diagram 1 - Vision 2 - Policies 3 - Strategic projects 4 .1 V i s i o n o F T h e F u T u r e the Basque chronic Patients Strategy aims to respond to the needs generated by the phenomena of chronicity in all the affected groups: chronic patients and their carers, health workers, and citizens in general. • for the chronic patients and their carers it will mean changing from a reactive system to a proactive system which will offer them a more integrated level of care (coordination between health levels and alignment with the social and employment agendas), more continuity during the development of the illness (from prevention to the end of life, including rehabilitation) and be more adapted to their needs. furthermore, they will be given a role to fulfil and greater responsibility in the management of their own health. All with the final objective of being able to offer patients better health results, with greater levels of satisfaction as far as care and quality of life are concerned.istockphoto - getty images 27
  30. 30. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country • for medical professionals it will represent the possibility of devoting more time to work on issues of higher added value and having access to the necessary tools (e.g. more complex diagnostics in primary care, tools to support changing patients behaviour). furthermore the idea is to that the time invested in routine work will be automated (e.g. prescriptions for long term treatment, coordination of the clinical history between levels of care, basic health advice by telephone, case management by nursing) and the tools will be given to the patients themselves or the carer. • for citizens there will be a double benefit. As tax payers they will benefit from a more efficient use of the systems resources, with the type and cost of each intervention being adjusted to meet the attention and care needs of each case, thereby contributing to the sustainability of the system. As potential chronic patients, they will participate in the prevention of chronicity and the promotion of their own health, avoiding the development of chronic conditions or at least reducing their impact on their health and quality of life. • for non-medical professionals and health service managers it will mean that their role will be given more recognition, they will have confirmation of their impact on health results and not only on the efficiency of the system, their co-leadership will be broadened, they will witness the breaking of barriers which limited their area of action and responsibility, as well enjoying the opportunity to share with other professionals new areas of influence and collaboration. Table 9: Vision of Strategy for Chronic Illnesses The Strategy for Chronic Illnesses aspires to substantially improve the lives of patients and carers, health professionals and citizens Vision Better health results Greater life satisfaction and Chronic Patients and quality their Carers Basque Health More time for work system adapted to E cient use of which has greater resources added value deal with Chronicity Prevention of Fewer routine chronicity and its Health jobs Citizens development Professionals28
  31. 31. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrythis change will have an impact both on Primary care and on hospital care. it is not aquestion of deciding where care should be provided, but accepting that care for chronicpatients nowadays is suboptimal mainly due to the lack of care continuity between ourlevels of care. thus the logic of this Strategy is based on the premise that we are facedwith a problem of organization of clinical and preventive practices, both with regard toprimary care and hospital care.care provided is still basically reactive to acute illnesses and episodes; that is, in a modelof acute illnesses the premise is to define the problem which is the subject of the clinicalconsultation, to diagnose it and to initiate a treatment, usually pharmacological. theconsequence of this model of organization is that, when it is applied to a chronic patient,that patient receives care which is more episodic than continuous, as this is how the systemhas been conceived. Moreover, the consultation is normally determined by the acuteproblems from which the patient is suffering. All this leads to a reactive model.By contrast, we propose moving to a model of organization which is more proactive in orderto ensure:• that patients have the confidence and the skills to manage their illness.• that patients receive care that provides optimum monitoring of their illness and prevents complications.• that there is a continuous monitoring system both remote and face-to-face.• that the patients have a self management plan, which has been mutually agreed with health professionals, with which to control their illness.• that we develop an organization with a preventive and continuous care logic, which is designed between the patient and the clinical team.experts agree that it is preferable to manage chronic illnesses in primary care, and themodels outlined in Section 2.3 of this document are based upon this logic. this strategycontinues this line of work, but it indicates that hospitals should also be innovative in theirmanagement of chronic patients, as in many cases they have to be admitted to hospital.thus hospitals play a fundamental role, as treating chronic patients during their acuteepisodes is part of the integral management of those patients.finally, what we are dealing with is a process of change which combines uniform elementsfor all patients and agents of the system – an essential ingredient to guarantee the necessarylevel of standardization in an ambitious strategic change – with the necessary adaptationof various local situations arising from users and service organizations. for this reason, wedefend the need to better balance the dichotomy between the corporative and the localperspective. that balance is achieved with certain global strategic frameworks, whichemanate from the centre and extend uniformly throughout the system and with the necessarylocal freedom required for local application. this balance is further explained in the lastchapter of this strategy.to realize this vision, it is necessary, not only to provide the system with the necessarytools, but also to change substantially the “way of doing things”, with respect to theorganization of care; a change to be made both by the patients themselves and by thesocial and health care professionals and managers. these changes are defined in the fivePolicies of care for chronic patients explained in the following chapter. 29
  32. 32. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 4.2 policies the policies described below correspond to the principal areas requiring change in order to be able to suitably address prevention, care, rehabilitation and health care for chronic patients. As has been previously mentioned, these polices do not aim to replace the current system of handling of acute illnesses, but in fact to complement it in order to be able to offer excellent and efficient care to chronic patients. to put each one of these policies into action, it will be necessary to strengthen the system in various areas, in order to prepare a more adapted model geared to managing the phenomena of chronicity. this section will focus on describing the aim and expected results of the policies, while details of the concrete strategic projects can be found in the following section. POLICY I. Adoption of a population health outlook, stratified and proactive population Table 10: Policies Health care for chronic patients will change with the introduction of five strategic policies I Focus on strati ed population health Policies II Promotion and Prevention of chronic illnesses III Responsibility and autonomy for patients IV Continuous care for the chronic patient V E cient interventions adapted to the patient’s needs Source: own elaboration health management and reduction of inequalities in health matters. Objective the objective of the focus of population health is to improve the health of the entire population and reduce the potential level of health inequality. this focus will also enable the analysis of the complexity and comorbidity levels of the population, and its segmentation with the aim of targetting resources to cover the different needs in a tailored and proactive way. Context and Focus this policy recognises both the diversity of the social, economic and environmental factors which influence the development and evolution of chronic illnesses, and the behavioural factors which affect health. it also helps identify how these causes determine the inequalities. in this way the specific needs of the different levels of the patients in question are responded to: from those who are in the final phase of their lives (receiving palliative care) to those who, although not yet chronically ill, present a series of risk factors which identifies them as potential chronic patients in the future; as well as recognising and facing up to the specific requirements of population groups such as the elderly and those who find themselves in a precarious social30
  33. 33. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryor economic situation (the groups most affected by chronic illnesses and in need of specificsocial interventions).focussing the policy in this way, the prevention and care for chronic illnesses must respondto the needs of the people from all backgrounds, both cultural and linguistic; of every age,from children to the elderly; from all socio-economic classes; from all areas, both rural andurban, and with no disparity between men and women.Specific Resultsthe result of this policy will be to identify the “target” groups of patients for certaininterventions. this requires both a stratification of the population according to their clinicalrisk and their health and socio-health needs, and also the association of each level ofstratification and patient typologies with the kind of interventions that evidence has provento be effective for chronically ill patients in the Basque country. eventually, this will allbe integrated in information systems and in the daily clinical duties of the medicalprofessionals, thereby personalising the treatment received by each patient.this integration is fundamental, as the stratification of the population and the populationfocus which it enables is a first essential step towards setting in motion the rest of thechronic illness management policies.furthermore, stratification will help bring about the change in mentality from a “patient”focus to a “population” focus which considers the individual beyond the acute episodesand also embraces prevention, rehabilitation, and medium-term care.Table 11Diagram of a possible pyramid of population stratification Patients with severe complexity Requires urgent health care coordination Level 4 ies vit Patients with medium level complexity cti Level 3 Suffer from complications and need na a certain level of management tio en Patients with reduced complexity ev Level 2 Well managed Pr Recently diagnosed Patients with no chronic illnesses Level 1 Healthy populationSource: Adaptation of the kaiser Permanente risk stratification 31
  34. 34. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country POLICY II. Prioritisation of health promotion and the prevention of illness. Objective A considerable number of chronic illnesses and their risk factors can be prevented and, consequently avoided. once they are present, their early diagnosis and detection often enables their progression and their negative and disabling effects to be limited. the objective of this policy is to create a framework of action, including proactive prevention measures and health promotion actions with regard to chronic illnesses, aimed at the different levels of the population pyramid: both for the healthy and for those persons with risk factors, as well as those who are already suffering from one or more chronic illnesses, but always emphasising an integral population approach. Context and focus Specifically, some risk factors such as the consumption of tobacco, alcohol, or other drugs, lack of physical activity, a badly balanced diet or unhealthy working conditions can be controlled, thereby avoiding the appearance and progression of a high proportion of many chronic illnesses. the aim, therefore, is to put tried and tested measures and interventions into action with the aim of preventing chronic illnesses. interventions will be combined both at an individual level and at the level of patient groups and risk groups. the proposal of specific interventions for health promotion and prevention of chronic illnesses must, necessarily, take into account the available scientific evidence. thus, the use of information systems and risk stratification of the attended population may be of great benefit when it comes to carrying out interventions at a more efficient level. health promotion actions must be aimed at raising awareness and informing the citizens about their health, at improving their lifestyle habits, at raising their awareness with regard to certain risk factors. As far as prevention actions are concerned, these must be introduced both at primary and secondary level care, stressing the usefulness of early detection in primary care and the capacity for contention of progression of the illness in secondary care. Specific results resulting from the policy will be an integrated set of prevention and health promotion actions of proven effectiveness in the Basque country, both at primary and secondary level, aimed at target groups of patients according to the results of the stratification. these actions should significantly reduce the prevalence of chronic illnesses and the deterioration in health of those patients who suffer from them. POLICY III. Promoting the active role of the citizens, encouraging their responsibility in the management of their disease and in patient autonomy Objective Promoting the increasing role of the citizen in dealing with chronicity. on the one hand, with self-care on the part of the chronic patients and their carers, as an essential lever to reach personalised based care with the necessary support of the healht care system at all levels. Self-care requires the active participation of the patients and their carers in administering healthcare and in the process of making informed decisions which are agreed on with the doctor, the patient and the carer. on the other hand, it requires their active participation in their own health promotion and the prevention of the appearance and development of chronic illnesses.32
  35. 35. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryContext and focuscare which is focussed on the individuals places them at the centre of their own healthcare, converting them into active patients and administrators of their own state of health.however, the traditional role of the patient and the carer in the health system is passivewith all the responsibility and knowledge centred on the doctor. this traditional role is upto a point coherent from the point of view of acute illnesses in which immediate anddecisive action is required in the case of a complex episode in which the patient onlyoccasionally participates. A chronic procedure, however, has long reaching effects andrequires intervention over a long period of time. Moreover, the patient or carer hasconsiderable influence over the effectiveness of the treatment and the progression of theillness depending on the rigour with which the treatment is adhered to and the lifestyleof the patient (e.g. tobacco, exercise, obesity).therefore, it is crucial to change the conventional role of the passive patient, receivingcare from the system, to that of an active patient/citizen, accountable for their own careand illness prevention.of course, the degree of participation and accountability of patients and carers is different,depending on the type and complexity of the process, the level of independence, andthe social-health situation of the patient. in any case, all patients and carers have theopportunity to participate in their care to an extent, as patients can be supported in thedevelopment of specific skills and resources in order to maximize their capability for self-care.Specific resultsthe specific result of this policy will be an array of interventions and tools which will enableself-management and promote the accountability of patients with regard to their owncondition. these interventions and tools will be incorporated into the daily clinical routineof the health professional –and in that of the social workers when relevant- and will be easilyaccessible and extensively used by the patients and their carers, with the support of patientsassociations. the eventual consequence will be a stricter level of adherence to the treatmentand lifestyles necessary to control and prevent the illness, and a more efficient use of theresources of the health and social systems.POLICY IV. To guarantee continuous care through the promotion of a multi-disciplinarycare programme, co-ordinated and integrated between the different services, carelevels and sectors.Objectivecare for citizens suffering from chronic pathologies involves numerous health care providersin different scenarios, such as Primary, Secondary and tertiary care, medium and longstay rehabilitation centres with a focus on acute and sub-acute cases, mental healthcentres, the social-health sector, health at work, community organizations and ngos,etc.integration and continuity in the provision of care are essential elements with which toguarantee that the necessary services are received at the right time and in the right way,optimizing health results and improving the experience of “the journey through the system”,in a process which begins with initial prevention and goes beyond the worsening of achronic illness until the point at which rehabilitation permits the citizen to resume a normallife. from the professional point of view, the target is to promote coordination to avoidduplication and to reach optimum management with regard to transitions between carelevels. 33