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  1. 1. Innovative Care for Chronic Conditions Organizing and Delivering High Quality Care forChronic Noncommunicable Diseases in the Americas
  2. 2. Innovative Care for Chronic Conditions: Organizing and Delivering High Quality Care forChronic Noncommunicable Diseases in the Americas
  3. 3. Innovative Care for Chronic Conditions: Organizing and Delivering High Quality Care forChronic Noncommunicable Diseases in the Americas
  4. 4. PAHO HQ Library Cataloguing-in-Publication DataPan American Health Organization.Innovative Care for Chronic Conditions : Organizing and Delivering High Quality Care for Chronic Noncommunicable Diseases in theAmericas. Washington, DC : PAHO, 2013.1. Chronic Disease. 2. Health Care Quality, Access, and Evaluation. 3. Innovation. 4. Americas I. Title.ISBN 978-92-75-117385(NLM classification: WT500 DA1)The Pan American Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.Applications and inquiries should be addressed to Editorial Services, Area of Knowledge Management and Communications (KMC),Pan American Health Organization, Washington, D.C., U.S.A., which will be glad to provide the latest information on any changes madeto the text, plans for new editions, and reprints and translations already available.© Pan American Health Organization, 2013. All rights reserved.Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of theUniversal Copyright Convention. All rights are reserved.The designations employed and the presentation of the material in this publication do not imply the expression of any opinion what-soever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city orarea or of its authorities, or concerning the delimitation of its frontiers or boundaries.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommendedby the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissionsexcepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the Pan American Health Organization to verify the information contained in this pub-lication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The respon-sibility for the interpretation and use of the material lies with the reader. In no event shall the Pan American Health Organization beliable for damages arising from its use.This document was prepared by Alberto Barceló, JoAnne Epping-Jordan, Pedro Orduñez, Silvana Luciani,Irene Agurto, and Renato Tasca.The preparation of this document benefited from contributions by Claudia Pescetto, Rubén Suárez, Victor Valdivia,Anand Parekh, Rafael Bengoa and Michael Parchman.Design and layout: Sandra Serbiano, Buenos Aires, ArgentinaPhoto Credits: WHO: Page 8/ PAHO: Pages 10, 12, 14, 17, 18, 21, 70, 74, 83, 86/ Shutterstock.com: Pages 22, 28, 36, 42, 58, 72,76, 80/ Depositphotos.com: Pages 48, 54, 64, Front Cover/ Photl.com: Page 5
  5. 5. Table of ContentsExecutive Summary .............................................................................................................11Background ..................................................................................................................................13Introduction.................................................................................................................................15 THE CHALLENGES ............................................................................................................................17 PREMATURE DEATH AND DISABILITY............................................................................................17 ECONOMIC HARDSHIP .....................................................................................................................17 POOR-QUALITY CARE .......................................................................................................................18The Chronic Care Model .............................................................................................. 23 PRODUCTIVE INTERACTIONS ..........................................................................................................24 EXPERIENCE SHOWCASE ................................................................................................................. 26Self-Management Support ............................................................................................ 29 EXPERIENCE SHOWCASE ................................................................................................................. 34Delivery System Design ....................................................................................................37 EXPERIENCE SHOWCASE ................................................................................................................. 40Decision Support.....................................................................................................................43 EXPERIENCE SHOWCASE ................................................................................................................. 46Clinical Information Systems ....................................................................................49 EXPERIENCE SHOWCASE ..................................................................................................................52The Health Care Organization .................................................................................55 EXPERIENCE SHOWCASE ..................................................................................................................57
  6. 6. Community Resources and Policies ....................................................................59 EXPERIENCE SHOWCASE ..................................................................................................................61Beyond the Chronic Care Model:Macro Level Considerations ......................................................................................65 POLICY IMPLICATIONS ....................................................................................................................65 INTEGRATIONOF SERVICES ............................................................................................................ 66 FINANCING ............................................................................................................................................... 69 LEGISLATION .....................................................................................................................................70 HUMAN RESOURCES AND INFRASTRUCTURE ............................................................................. 72 PARTNERSHIPS...................................................................................................................................74 LEADERSHIP AND ADVOCACY ........................................................................................................75A Method for Introducing Change ...................................................................... 77Implementing and Improving CNCD Carein the Americas ........................................................................................................................81 THE CHRONIC CARE MAP: EXPERIENCE SHOWCASE ...................................................................82Conclusions ..................................................................................................................................87Recommendations ............................................................................................................... 90List of Abbreviations.......................................................................................................... 92References ..................................................................................................................................... 94Annex 1: Contributors ....................................................................................................102
  7. 7. WHO/Pierre Albouy 8
  8. 8. Universal [health care]coverage is the single mostpowerful social equalizerOpening Remarks by the Director-General of theWorld Health Organization at the 64th Session of theWHO Regional Committee for The AmericasDr. Margaret Chan17 September 2012Washington DC 9
  9. 9. I will work to enhance this Organization’s[PAHO’s] ability to work side-by-side with ourMember States to develop health systems andservices, and promote models of care, whichadvance universal access.Change in Health, Health for ChangeInaugural Address of Dr. Carissa F. Etienne asDirector of the Pan American Health Organization31 January 2013Washington DC 10
  10. 10. Executive Summary Care for chronic noncommunicable diseases (CNCDs) such as cardiovascular disease (CVD), diabetes, cancer,and chronic obstructive pulmonary disease (COPD) is a global problem. Research demonstrates that the vastmajority of people with CNCDs do not receive appropriate care. This report describes a model of health carethat could deliver integrated management of NCDs within the context of primary health care (PHC), and providespractical guidance for health care program managers, policy-makers, and stakeholders on how to plan and deliverhigh-quality services for people with CNCDs or CNCD risk factors. Key implications of integrated management atthe policy level are also discussed, including the financial and legislative aspects of care and human resourcedevelopment. The report includes a list of examples of effective intervention for each component of the ChronicCare Model. Furthermore, unpublished country based examples of the implementation of good practices in chroniccare are showcased throughout the document. The document concludes that the Chronic Care Model should beimplemented in its entirety since its components have synergistic effects, where the whole is greater than thesum of the parts. Policy reforms and universal access to care are critical elements leading to better outcomes andreducing disparities in chronic disease care. It is critical to integrate PHC-based chronic care into existing servicesand programs. Chronic diseases should not be considered in isolation but rather as one part of the health statusof the individual, who may be susceptible to many other health risks. A patient-centered care system benefits allpatients, regardless of their health conditions or whether his/her condition is communicable or noncommunicable.A care system based on the Chronic Care Model is better care for all, not only for those with chronic conditions.Primary care has a central role to play as a coordination hub, but must be complemented by more specialized andintensive care settings, such as diagnostic labs, specialty care clinics, hospitals, and rehabilitation centers. Finallythe ten recommendations for the improvement of quality of care for chronic conditions are:1. Implement the Chronic Care Model in its entirety.2. Ensure a patient centered approach.3. Create (or review existing) multisectoral policies for CNCD management including universal access to care, aligning payment systems to support best practice.4. Create (or improve existing) clinical information system including monitoring, evaluation and quality improve- ment strategies as integral parts of the health system.5. Introduce systematic patient self-management support.6. Orient care toward preventive and population care, reinforced by health promotion strategies and community participation.7. Change (or maintain) health system structures to better support CNCD management and control.8. Create PHC-led networks of care supporting continuity of care.9. Reorient health services creating a chronic care culture including evidence-based proactive care and quality improvement strategies.10. Reconfigure health workers into multidisciplinary teams, ensuring continuous training in CNCD management. 11
  11. 11. Participants in the Working Group Organizingand Delivering High Quality Care for ChronicNoncommunicable Conditions in the Americas13-14 December 2012Washington DCFront row: Tomo Kanda, Elisa Prieto, Lisbeth Rodriguez, Sonia Angel, Tamu Davidson-SadlerBack row: Frederico Guanais, Micheline Meiners, Rafael Bengoa, Anand Parekh, Alberto Barceló,Renato Tasca, Sandra Delon, Maria Cristina Escobar, JoAnne Epping-Jordan, Sebastian Laspiur,Silvana Luciani, Anselm Hennis, Pedro Orduñez 12
  12. 12. Background This report describes a model of health care that could deliver integrated management of NCDs within thecontext of primary health care (PHC), and provides practical guidance for health care program managers, poli-cy-makers, and stakeholders on how to plan and deliver high-quality services for people with CNCDs or CNCD riskfactors. Key implications of integrated management at the policy level are also discussed, including the financialand legislative aspects of care and human resource development. The implications of this type of care for healthcare systems, as well as patients and communities, are also analyzed. Recommendations and suggestions aremade based on evidence and practical experiences. This report is not an exhaustive review of models for inte-grated management of NCDs and does not attempt to capture the full breadth of experiences across all countriesin the Region. Many individuals contributed with examples that are showcased along the document. A full list ofcontributors appears in annex 1. The working group Organizing and Delivering High Quality Care for Chronic Noncommunicable Conditions inthe Americas took place on December 13-14, 2012 in Washington DC with the participation of 20 experts andhealth officials from 10 countries. During this two day working group, participants reviewed different aspects ofthe Chronic Care Model, including specific evidence for interventions and a set of general recommendations. Acomplete list of participants is presented in Annex 1. As a result of the working group, for each component of theChronic Care Model, a list of examples of evidence-based interventions is included in this report under sectionsnamed Examples of Effective Interventions. These evidence based interventions come from articles that wereidentified in a rapid review of literature using the PubMed and the Cochrane databases. The initial review includedmore than 200 articles, while a total of 37 high quality articles (mainly systematic reviews) were finally included inthe list. The identified evidence-based interventions should be considered with care since some adaptation maybe necessary, given that the original interventions may have been developed in settings with different social andeconomic contexts. Details about the literature search and the working group are available from the authors. The report is divided into ten main sections:1. Executive Summary. This session presents a summary of the issues covered by this document.2. Challenges. This section describes the current mismatch between the CNCD burden (a rapidly changing epi- demiological profile, and ever-increasing economic impact) and the outdated ways in which most health care systems are organized to manage and deliver care for these conditions.3. Model of care. This section summarizes approaches and models that can help inform and organize efforts to improve health care for the effective prevention and management of CNCDs.4. Policy implications. In most parts of the Region, a positive policy environment that supports integrated CNCDs care can help reduce the CNCD burden. Financing, legislation, human resources, partnerships, and leadership and advocacy are some of the policy-level domains that influence the quality of integrated CNCDs management.5. Method for introducing change. The Breakthrough Series (BTS) and the underlying principles of quality im- provement provide a structure for bringing about improvement in health systems.6. Implementing and improving CNCD care in the Americas. Numerous initiatives have been undertaken in the Region to improve the integrated management of CNCDs; a set of case studies is showcased for each com- ponent of the Chronic Care Model.7. Conclusion. This section reviews the most important issues outlined throughout the document for the imple- mentation of the Chronic Care Model.8. Recommendations. This section identifies key actions to improve outcomes across a range of health sys- tems. These recommendations were discussed during the previously mentioned working group.9. References. A complete list of references with links to documents available online.10. Annex 1. This section contains a full list of contributors. 13
  13. 13. 14
  14. 14. IntroductionC are for chronic noncommunicable dis- eases (CNCDs) such as cardiovascu- lar disease (CVD), diabetes, cancer,and chronic obstructive pulmonary disease(COPD) is a global problem. Research demon-strates that the vast majority of people withCNCDs do not receive appropriate care. Onlyabout half are diagnosed, and among thosepatients, only about half are treated. Amongthe quarter of people with CNCDs who do re-ceive care, only about half achieve the desiredclinical treatment targets. Cumulatively, onlyabout 1 in 10 people with chronic conditionsare treated successfully (1). This is mainly theresult of inadequate management, but also ofinsufficient access to care and the existenceof numerous financial barriers (2). 15
  15. 15. Political and public health lead- diabetes, hypertension, heart dis-ers increasingly recognize the need ease, and certain types of cancers,to take urgent action to address and heart disease may be a long-the problem of CNCDs. Internation- term complication of more than oneal action is under way, as shown at chronic condition, such as diabetesthe United Nations (UN) High-level and hypertension.Meeting (HlM) on the Prevention and In addition to integrated manage-Control of Non-communicable Dis- ment of CNCDs, general integrationeases (NCDs) held in New York in of this type of care within healthSeptember 2011(3), and the World services is also essential. A personConference on Social Determinants with a chronic condition should beof Health, held in Rio de Janeiro in managed in a holistic manner withinOctober 2011 (4). At these meet- the context of other existing healthings, world leaders recognized that problems and programs (e.g., inte-the global burden and threat of NCDs grated programs for managementconstitute one of the major challeng- of chronic or communicable diseas-es for development in the 21st centu- es, or maternal and child health is-ry, undermining social and economic sues). This makes sense becausegrowth and threatening the achieve- there are several associations be-ment of development goals. They tween various chronic diseasesalso acknowledged governments’ and communicable diseases (e.g.,leading role in and responsibility to diabetes and tuberculosis (TB); vi-respond adequately to this challenge. ral infections and cancer, includingAmong other things, the political human papillomavirus (HPV) anddeclaration of the UN HlM called for cervical cancer, and hepatitis B and“promot[ing] access to comprehen- liver cancer; AIDS and cancer; andsive and cost-effective prevention, AIDS and the metabolic syndrome).treatment and care for the integrated Chronic disease should not be con-management of non-communicable sidered in isolation but rather asdiseases ... .” one part of the health status of Integrated management of the individual, who may be suscep-CNCDs makes sense for at least tible to many other health risks. Athree important reasons. First, most patient-centered care system bene-people have more than one risk fac- fits all patients, regardless of theirtor and/or CNCD (e.g., hyperten- health conditions.sion and obesity, or hypertension The optimal solution for effec-and diabetes and/or asthma) (5). tive CNCD prevention and manage-Therefore, it makes sense to treat ment is not merely scaling up ”busi-their conditions within an integrated ness-as-usual” health care deliveryframework of care. Another reason systems but rather strengthening andthat integrated care makes sense is transforming these delivery systemsthat most CNCDs place similar de- to provide more effective, efficient,mands on health workers and health and timely care. The solution is notsystems, and comparable ways of to create a system that is exclusiveorganizing care and managing these for CNCDs but rather to ensure thatconditions are similarly effective the health system is fully preparedregardless of etiology. Third, most and equipped to provide high qualityCNCDs have common primary and continuous care for those who needsecondary risk factors. For exam- it, which is the vast majority of theple, obesity is a major risk factor for population under care. 16
  16. 16. sity (affecting 26% of adults—moreTHE than any other region); diabetes (af- fecting 5% –10% of the population);CHALLENGES and tobacco use (about 22% of the population). Without appropriate The global burden of CNCDs con- action, it is projected that thesetinues to grow, both globally and in factors will contribute enormouslythe Region, placing even more de- to the increase in the burden of dis-mands on already-strained health ease in the Americas (7).systems. ECONOMICPREMATURE HARDSHIPDEATH AND CNCDs also place a grave burdenDISABILITY on countries at the macroeconom- ic level. In 2010, the global cost of Worldwide, in 2008, CNCDs CVDs was estimated at US$ 863 bil-caused an estimated 36 million lion; this figure is estimated to rise todeaths, representing 63% of all more than US$ 1 trillion by 2030—deaths. These deaths were due an increase of 22%. For cancer, themainly to CVDs (48%), cancers 13.3 million new cases reported in(21%), chronic respiratory diseases 2010 were estimated to cost US$(12%), and diabetes (3%). CNCDs 290 billion, and CNCD-related costsare a major concern among ageing are expected to reach US$ 458 bil-populations not only in high-income lion by the year 2030. Diabetes costscountries but also in low-income the global economy nearly US$ 500countries, where the burden of these billion in 2010, a cost that is project-diseases is rising disproportionately ed to rise to at least US$ 745 billion(6). Major risk factors for CNCDs by 2030, with developing countriesare unhealthy diet and physical in- assuming a much greater share ofactivity, leading to overweight and the outlays (8).obesity, as well as tobacco use and Other data from the Region ofharmful use of alcohol. Macro-lev- the Americas provide similar re-el catalysts of these conditions in- sults. The current cost of diabetesclude population growth and ageing, treatment is estimated to be doubleurbanization, poverty, and inequity. the current cost of HIV treatment— domestic product (GDP) is expected The Region of the Americas pres- reaching as much as US$ 10.7 bil- to reach 3.21% by 2015 (8). In Trin-ents a similar pattern. Annually, al- lion in Latin America alone. In 2010, idad and Tobago, the current costmost 4 million people in the Region spending on diabetes accounted for of hypertension and diabetes isdie from CNCDs, comprising 76% of 9% of the total health expenditure estimated to represent 8% of GDP.all deaths. More than one-third of in South and Central America and In Mexico, assuming that the preva-these deaths are premature (occur- reached 14% in North America, in- lence of diabetes and hypertensionring before age 70), and most are cluding the English-speaking Carib- continues to rise as predicted, it haspreventable and can be postponed. bean countries and Haiti. In Brazil, been estimated that national healthImportant CNCD risk factors in the researchers predict that the project- spending will have to increase byRegion are hypertension (affecting ed national income loss attributable 5% –7% per year just to meet the20% –40% of the population); obe- to CNCDs as a percentage of gross needs of the newly diagnosed (9). 17
  17. 17. those diseases; an additional 15%POOR-QUALITY of the population engage in behav- iors which increase their risk forCARE CNCD, such as smoking and phys- ical inactivity; and 5% require pre- Many people with CNCDs fail to ventive services because they arereceive appropriate care. This failure in the at risk age groups for breast,to provide appropriate care can be cervical or prostate cancer. Overallattributed to both access and quality only around 10% of the adult popu-issues, and is often experienced to a lation may be considered as havinggreater extent among disadvantaged low risk for CNCD and therefore notsubgroups of the population (10). A at apparent immediate need for anysurvey of adults with ”complex care chronic care action (Barceló A, cal-needs” across 11 countries, includ- culated with data from the Centraling Canada and the United States, America Diabetes Initiative, unpub-revealed substantial gaps in coordi- lished observation, 2013).nation (11). This study showed that Another factor influencing the qual-in the United States, approximately ity of care for chronic conditions is40% of respondents reported that the workload and the capacity of thethey did not receive adequate health health system for effectively seeingcare once a chronic condition became all those in need. Overcrowded wait-apparent. Furthermore, of those that ing rooms and clinics may be a com-received care, 20% of cases were mon environment nowadays in manydeemed to receive clinically inappro- settings because of the massivepriate care (12). increase in the number of patients The quality of health care for seeking care for CNCD. A rationalCNCDs in low- and middle-income use of the available resources for thecountries is also of concern. These management of CNCD is thus critical.countries often struggle with the For example an adequate amountcomplexity of having insufficient re- of health provider’s time is neededsources combined with inadequate for medical encounters to effectivelyaccess to necessary services, carry the myriad of tasks required fordrugs, and technologies. At the chronic care, including medical andsame time, many of these countries psychological management, self-man-are still struggling with communica- agement support and data collection,ble diseases, as well as maternal among others.and infant health issues. Health fa- The consequences of poor-qual-cilities frequently lack the key exam- ity care are substantial. From anination supplies, diagnostic tests, economic perspective, health careand medications needed to provide costs become excessive whenessential care for CNCDs. CNCDs are poorly managed. Poor Data from PAHO suggest that execution or lack of widespreadabout 90% of adults may require adoption of known best care pro-some sort of medical action relat- cesses (such as preventive careed to CNCDs. Around 40% of adults practices that have been shown toare reported with diagnosed CNCD be effective) results in wasted re-(diabetes, hypertension, hypercho- sources. Waste also occurs whenlesterolemia or obesity), while 30% patients “fall through the cracks”have undiagnosed conditions which due to fragmented care. Poor-qualityputs them at high risk to develop care results in health complications, 18
  18. 18. hospital readmissions, decline infunctional status, and increased de-pendency, especially for those withCNCDs, for whom coordination ofcare is essential (13). Individuals,families, health care organizations, Strategic Approaches: The Worldgovernments, and taxpayers collec-tively pay the price. WHO Global Strategy Health Or- ganization Across the Region, poor-quality and Action Plan for (WHO) Glob-care also results in poor patient out-comes. More than half of those diag- the Prevention al Strategy fornosed with diabetes or hypertension the Prevention anddo not achieve treatment goals. Re- and Control Control of NCDs (26)search in both population and clinicalsettings conducted between 2003 of NCDs (“Global Strategy”) and corresponding Action Planand 2010 showed that among thosewith hypertension or diabetes, less provide key policy guidance tothan 50% achieved good blood pres- assist decision-makers in reshapingsure (14) or glycemic control (15–20) health systems and services to tackle CNCDs,respectively. A study on quality of dia- particularly in settings where resources are limited. Thebetes care provided by general prac- guidelines for national governments include the following:titioners in private practice in nine • Use a unifying framework to ensure that actions at allcountries of Latin America (Argentina,Brazil, Chile, Costa Rica, Ecuador, levels and by all sectors are mutually supportive;Guatemala, Mexico, Peru, and Vene- • Use integrated prevention and control strategies, focus-zuela) based on 3,592 patient ques- ing on common risk factors and cutting across specifictionnaires answered by physicians diseases;revealed that 58% of patients had a • Combine interventions for the whole population andpoor diet, 71% were sedentary, and for individuals;79% were obese or overweight. Poorglycemic control was observed in 78% • Use a stepwise approach, particularly in countries thatof the patients; the proportion of pa- do not have sufficient resources to carry out all recom-tients with glycated hemoglobin (A1c) mended actions;< 7.0% was 43%; and comorbid con- • Strengthen intersectoral action at all stages of policyditions associated with type 2 diabe- formulation and implementation to address the majortes were reported in 86% of patients determinants of the chronic disease burden that lie out-(17). Other studies indicated similargaps in care. Along the U.S.-Mexico side the health sector;border, many adult Hispanics with dia- • Establish relevant and explicit milestones for each lev-betes do not receive evidence-based el of intervention, with a particular focus on reducingcare (19). In Brazil, patients with hy- health inequalities.pertension and/or diabetes are not Forming key partnerships with the private sector, civil so-prescribed medications at sufficient ciety, and international organizations is also recommend-levels to control these diseases (21).In southern Brazil, 58% of patients ed as the best way to implement public policies.with CNCDs did not undergo mea- Source: Reference (26).surement of their weight, height, andblood pressure, and did not receivepreventive recommendations (22).Although cancer incidence remains 19
  19. 19. high globally, death rates for many but the organization of health care cancer types have declined in recent has not (25). Although some coun- years in the United States and other tries have taken steps to redesign developed countries owing to better their health care systems to accom- treatments. However many develop- modate the growth in the CNCD bur- ing countries are still experiencing den, most systems have not kept extremely high case fatality rates as pace at the level that is needed to consequences of late diagnosis, lack meet changing population needs, of access to early detection and care and quality gaps remain. Other and sub-optimal management (23). countries are still using approaches Breast cancer for example, is diag- that were designed for a set of pre- nosed in more than 100,000 women vailing health problems that are no in Latin America and the Caribbean, longer the main causes of morbidity and causes approximately 37,000 and mortality. While acute medical deaths annually. Although some im- problems will always require the at- provements have been seen recently tention of health workers, approach- in some countries, in the Region of es that are oriented toward acute the Americas still 30-40% of women illnesses are becoming increasingly with breast cancer are diagnosed at inadequate to address the growing late stages, compared to only 10% population of people with CNCDs. in industrialized countries (24). Col- The attributes needed for optimal lectively, these results indicate that management of CNCDs are summa- despite some progress in the Region, rized in Table 1. Care should be inte- management of CNCDs—particularly grated across time, place, and con- diabetes hypertension and cancer— ditions. Health care team members is suboptimal overall. need to collaborate with one anoth- What is the cause of this care er as well as with patients and their failure? In essence, there is a mis- families to develop treatment goals, match between the most prevalent plans, and implementation strate- health problems (CNCDs) and the gies centered on patient needs, val- ways in which health care systems ues, and preferences. Collectively, in many countries are organized to health care personnel must to be deal with them. This mismatch is able to provide the full spectrum of historical in nature and can be un- health care services, from clinical derstood by looking back to previous prevention through rehabilitation eras when acute, infectious diseas- and end-of-life care. Planned, pro- es were the most prevalent health active care and self-management problems. Today, the epidemiologi- support are other hallmarks of this cal profile has shifted considerably, type of care. As described in the following sec- tion, integrated health care modelsTABLE 1. Attributes of Effective Care for Chronic Conditions that transcend specific illnessesOUTDATED CARE EFFECTIVE CARE and promote patient-centeredness provide a feasible solution for intro-• Disease-centered • Patient-centered ducing effective care. Including evi-• Specialty care/hospital-based • PHC–based dence-based approaches can bring• Focus on individual patients • Focus on population needs increased coherence and efficiency to health care systems and pro-• Reactive, symptom-driven • Proactive, planned vide a means for improving quality• Treatment-focused • Prevention-focused across a range of CNCDs. 20
  20. 20. Strategy for the Preventionand Control ofNoncommunicableDiseases Complementar y2012–2025 to the WHO Glob- al Strategy, the updated Regional Strategy and Plan of Action (27) for the Prevention and Control of NCDs 2012–2025 (“Regional Plan”), which was spurred bythe 2011 political declaration of the UN HlM on NCDs,highlights four key objectives:(a) Multisectoral policies and partnerships for NCD preven-tion and control: Build and promote multisectoral actionwith relevant sectors of government and society, includingintegration into development and economic agendas.(b) NCD risk factors and protective factors: Reduce theprevalence of the main NCD risk factors and strengthenprotective factors, with emphasis on children and adoles-cents and on vulnerable populations; use evidence-basedhealth promotion strategies and policy instruments, in-cluding regulation, monitoring, and voluntary measures;and address the social, economic, and environmental de-terminants of health.(c) Health system response to NCDs and risk factors: Im-prove coverage, equitable access, and quality of care forNCDs and risk factors, with emphasis on primary healthcare and strengthened self-care.(d) NCD surveillance and research: Strengthen countrycapacity for surveillance and research on NCDs, their riskfactors, and their determinants; and utilize the results ofthis research to support evidence-based policy and pro-gram development and implementation.Source: Reference (27) 21
  21. 21. 22
  22. 22. The Chronic Care Model S everal organizational models for CNCD management have been pro- posed and implemented internation- ally. Perhaps the best known and most in- fluential is the Chronic Care Model (CCM; see Figure 1) (28, 29), which focuses on linking informed, activated patients with proactive and prepared health care teams. According to the CCM, this requires an ap- propriately organized health system linked with necessary resources in the broader community. 23
  23. 23. FIGURE 1. The Chronic Care Model PRODUCTIVE INTERACTIONS All system elements described in the CCM are designed to support the development of an informed, proactive patient population and prepared, proactive health care teams. On the provider side, prepa- ration means having the necessary expertise, information, and resourc- Infomed, Productive Prepared, es to ensure effective clinical man- Activated Interactions Proactive agement. It also means having time- Patient Practice Team ly access to the necessary equip- ment, supplies, and medications needed to provide evidence-based care. Proactivity implies the ability to anticipate patients’ needs, to prevent illnesses and complications through risk factor reduction, and to plan care in a manner that does A number of countries have im- which are based on primary care not depend on acute exacerbationsplemented (adopted or adapted) the and integrated service networks. or symptoms as the sole triggerCCM (30). In 2002, WHO produced PAHO’s Integrated Health Service for clinical encounters. On the oth-an expanded version of the model— Delivery Network (IHSDN) is the rec- er side of the interaction, patientsthe Innovative Care for Chronic Condi- ommended response for the health must have information, education,tions (ICCC) Framework, which gives care organization to the PHC strate- motivation, and confidence to actgreater emphasis to community and gy. IHSDNs are responsible for opti- as partners in their care.policy aspects of improving health mizing the health status and clinical The central role of this partner-care for chronic disease (31, 32). Oth- outcomes of a defined population. ship between providers and pa-er related models are being used to They are comprehensive in that the tients is a substantial change fromguide the provision of CNCD care with- services they provide cover all lev- traditional ways of organizing andin certain countries (33–35). els of prevention and care, and are delivering care. According to the The CCM and related models coordinated or integrated among all CCM, chronic disease managementemphasize the central importance care levels and settings, including (CDM) is most effective when pa-of PHC and the recognition that the the community. IHSDNs also aim to tients and health workers are equalbest clinical outcomes can be ob- provide services that are continuous partners and both experts in theirtained when all model components over time (i.e., provided throughout own domains: health workers withare interconnected and working in the population’s life cycle), proac- regard to clinical management ofa coordinated manner. The success tive and not reactive. Other points the condition, and patients withof this approach is borne out by ev- of intersection between the CCM regard to their illness experience,idence on what works: research to and IHSDN are their emphases on needs, and preferences (43). Healthdate has shown that multidimen- 1) multidisciplinary teams, 2) care workers’ ability to elicit and discusssional changes have the greatest that is patient-centered, and 3) in- patients’ beliefs and to activateeffects (36–39). tegrated information systems that patient participation shared deci- The CCM and related models link the network with data. The rela- sion-making has been shown to im-espouse principles that are highly tion between IHSDNs and the CCM prove adherence to treatment plansconsistent with PAHO’s approaches is explored in more detail in another and medication as well as a rangefor strengthening health systems, PAHO publication (40). of other health outcomes (44–46). 24
  24. 24. Improving ChronicImproving Illness Care (ICIC) is The InstituteChronic a national program of for Healthcare the Robert Wood John- TheIllness Care son Foundation dedicated Improvement Insti- to the idea that United States tute for health care can do better. ICIC Health- has worked for more than a decade care Improve- with national partners toward the goal of ment (IHI), an in-bettering the health of chronically ill patients by dependent not-for-profithelping health systems, especially those that serve organization based in Cambridge,low-income populations, improve their care through Massachusetts, is a leading inno-implementation of the Chronic Care Model. Some vator in health and health careof the most useful ICIC tools are the Assessment of improvement worldwide. IHI isChronic Illness Care (ACIC) and the Patient Assess- dedicated to optimizing healthment of Chronic Illness Care (PACIC). The ACIC care delivery systems, driving thequestionnaire is a quality improvement tool devel- Triple Aim for populations, real-oped by ICIC to help organizations evaluate the izing person- and family-centeredstrengths and weaknesses of chronic condition care care, and building improvementdelivery in six areas: community linkages, self-man- capability. IHI professional de-agement support, decision support, delivery system velopment programs — includingdesign, information systems, and organization of conferences, seminars, and audiocare. The content of the ACIC derived from evi- and web-based programs — in-dence of the implementation of the Chronic Care form every level of the workforce,Model and it has shown to be responsive to system from executive leaders to front-changes and other measures of quality improve- line staff. For the next generationment interventions. The ACIC is being used thor- of improvers, IHI provides onlineoughly across the world and has been translated to courses and an international net-various languages. The PACIC is a questionnaire work of local chapters throughmeasuring specific items related to the application its Open School. IHI provides aof the Chronic Care Model from the patient point wealth of free content through itsof view. When paired with the ACIC, the PACIC website.survey offers consumer and provider perspectives of Source: The Institute for Healthcare Improvement (IHI). For more infor-the provided services. mation visit http://www.ihi.orgSource: References (29, 41-42). 25
  25. 25. EXPERIENCE SHOWCASE Canada: Chronic Disease Management, Alberta Health Services This intervention encourages a collaborative, integrated community approach to CDM. It emphasizes patient-centered care and coordi- nation across the care continuum, from health promotion and prevention to early detection and primary, secondary, and tertiary care. Between baseline and one-year follow-up, there was a 17% in- crease in the number of diabetes patients with an A1c test (essential for diabetes monitoring), a 13% increase in the number of patients with dyslipidemia and triglyceride test, a 19% decrease of hospitalization among patients with COPD, and a 41% and 34% decrease in hospitalizations and emergency visits, respectively. Source: Reference (47). Mexico: Veracruz Initiative for Diabetes Awareness A demonstration project was conducted in five centers (with an additional group of five centers providing usual care and serving as a study control). The CCM was implement- ed to improve the quality of diabetes care in the twin cities of Veracruz and Xalapa, Mexico. Specific interventions included in-service train- ing for health professionals, a structured diabetes self-management program, and the strengthening of a referral/back-referral system. Post-intervention measures improved significantly across intervention centers. The percentage of people with good blood glucose control (A1c<7%) rose from 28% prior to the intervention to 39% post intervention. In addition the percentage of patients who met three or more quality improvement goals rose from 16.6% to 69.7%, while this figure dropped from 12.4% to 5.9% in the control group. The methodology focused strate- gically on the primary health care team and the participation of peo- ple living with diabetes. Health team participants introduced mod- ifications to address health care problems that they had identified in four areas of the chronic care model (self-management support, decision support, service delivery design, and information system). The project was monitored by completing the ACIC questionnaire at the beginning (LS1) and at the end (LS3) of the intervention. The component achieving the highest score at the end of the intervention was self-management support. By LS3 all intervention centers im- proved their ACIC scores, most of them going from level C to level B. The project demonstrated that an integrated approach can improve the quality of diabetes care in primary health care settings. Source: References (48, 49). 26
  26. 26. Honduras: Honduras Fighting Diabetes Honduras Fighting Diabetes is an ongoing intervention project that began in 2012 and it is expected to be im- plemented during the next three years with support from the World Diabetes Foundation (WDF). Its main purpose is ensuring access to a comprehensive diabetes preven- tion and control program in primary and secondary care in 14 units from the Ministry of Health and the Honduran Institute of Social Security. The project promotes the use of a package of interventions based on the PEN strategy (Pack- age of Essential Intervention) of WHO, at the same time it devises mechanisms to organize chronic care and strengthens preventive activ-ities at the grass roots level. Activities for this project include the strengthening ofintegrated care by producing and disseminating evidence based guidelines and pro-fessional training. In addition these activities will be paired with community activitiespromoting healthy nutrition, physical activity, and the prevention of smoking and ofthe excessive use of alcohol. The Chronic Care Passport is used to foster patient andhealth provider collaboration. It is expected that after the success of the implement-ed activities in the 14 demonstration sites, the project will be expanded to a nationalstrategy that will result in improvements of the quality of integrated care as well asa reduction in the burden of diabetes and of other chronic diseases in Honduras.Source: Montoya R, PAHO Honduras (personal communication) Dominican Republic: Program for the Prevention and Control of Non-Communicable Diseases (PRONCEC) The purpose of this ongoing collaborative project is to improve, on a continuous basis, the quality of care for people with chronic diseases. PRONCEC is based on the application of the CCM and the BTS methodolo- gy. Five provinces located on the Dominican-Haiti border participate in PRONCEC. These border provinces are con- sidered underserved populations with a demonstrated high prevalence of CNCD. In addition the region hosts an economicallychallenged population with a high concentration of displaced persons from Haiti. Theproject began with the assessment of the services provided by the National PrimaryCare Units (UNAP) in participating provinces. The assessment included visits bythe intervention team, the completion of the ACIC questionnaire as well as a clinicalchart review. Gaps in chronic care were evident across the evaluated centers. Anintervention plan was developed in accordance with the results of the assessment,in collaboration with health authorities and providers. The plan includes the trainingof multidisciplinary teams in the integrated clinical management of CNCDs as well asin self-management support. Other measures include the strengthening of the refer-ral/back-referral system and increasing the capacity of the second level of care toprovide high quality integrated specialized services. PRONCEC is monitored throughperiodic evaluations and learning sessions.Source: Estepan T, Ministry of Health, Dominican Republic (personal communication, 2013) 27
  27. 27. 28
  28. 28. Self-Management SupportKEY ACTIONS FOR SELF-MANAGEMENT SUPPORT Ensure patient participation in the process of care; Promote the use of lay or peer educators; Use group visits; Develop patient self-regulatory skills (i.e., managing health, role and emotions related to chronic conditions); Promote patient communication skills (especially with regard to interactions with health profes- sionals and the broader health system); Negotiate with patient goals for specific and moderately challenging health behavior change; Stimulate patient self-monitoring (keeping track of behaviors); Promote environmental modification (creating a context to maximize success); Ensure self-reward (reinforcing one’s behavior with immediate, personal, and desirable rewards); Arrange social support (gaining the support of others); Use the 5As approach during routine clinical encounters.EXAMPLES OF EFFECTIVE INTERVENTIONS Group based self-management support for people with type 2 diabetes (50) Self-monitoring of blood pressure specially adjunct to care (51) Patient educational intervention for the management of cancer pain alongside traditional analge- sic approaches (52) Patient educational intervention using the 5 As for reducing smoking, harmful use of alcohol and weight management (53) Training for better control blood glucose and dietary habits for people with type 2 diabetes (54) Lay educator led self-management program for people with chronic conditions, including arthritis, diabetes, asthma and COPD, heart disease and stroke (55-57) Self-management support that involves a written action plan, self-monitoring and regular medical review for adults with asthma (58) Self-management support for people with heart failure to reduce hospital readmission (59) Patient oriented interventions such as those focused on education or adherence to treatment (60) 29
  29. 29. S elf-management is a group of tasks that an individual must undertake to live well with one or more chronicconditions. The tasks include gaining con-fidence to deal with medical management,role management, and emotional manage-ment (modified from reference 61). Self-management support is de- es or exacerbations; making appro-fined as the systematic provision of priate decisions concerning wheneducation and supportive interven- to seek professional assistance;tions by health care staff to increase and communicating and interactingpatients’ skills and confidence in appropriately and productively withmanaging their health problems, in- health workers and the broadercluding regular assessment of prog- health system (62). Major researchress and problems, goal setting, and reviews have found that self-man-problem-solving support (61). agement support is an important el- Self-management support is a ement of improved health outcomeskey element of the CCM because all for CNCDs (36, 43, 63). One reviewCNCDs require the active participa- found that 19 of 20 studies that in-tion of patients in promoting their cluded a self-management compo-health and pre¬venting the emer- nent effectively improved care (37).gence and development of chronic In the conceptual framework ofdiseases and related complica- the CCM (see Figure 1), self-manage-tions. Typical self-care activities ment support is positioned acrossinclude healthy lifestyle, prevention the community and the health sys-of complications, adherence to tem, reflecting the fact that it can betreatment plan and medication, and provided in a range of venues andhome monitoring of symptoms and formats. Routine clinic visits provideobjective illness indicators. Other excellent opportunities to build andessential self-management func- reinforce self-management skills.tions include recognizing and acting Alternatively, self-management sup-upon ”red flags”— symptom chang- port can be provided during health 30
  30. 30. FIGURE 2. The “5As” Self-Management Model Self-management model with 5Asworker–led group sessions, or ingroups run by lay leaders in healthcare settings or community ven- ARRANGE: specify A SSESS: knowledge, beliefs,ues. Telephone- and Internet-based follow-up plan behaviorself-management programs are alsovery promising modalities. Within the formal health caresystem, the “5As” model (64-65)(see Figure 2) can be used to de- Personalvelop self-management plans for Action Planpatients. This model is a series offive interrelated and iterative steps A SSIST: problem solving approach A DVISE:(assess, advice, agree, assist, and provide specific information identify potential barriers and about health risks and benefitsarrange). A major advantage of the strategies/resources for of change5As approach is that it is easy to overcoming themunderstand, remember, and use. Italso serves as a flexible approachthat can be applied in the course of A GREE: collaborativelyroutine clinical encounters (i.e., it isnot a stand-alone self-management set goals basedintervention but rather an approach on patientsdesigned to be integrated into nor- preferencesmal professional practice). The 5A sequence begins with an Sources: Whitlock et al., Am J Prev Med 2002 22(4): 267-284assessment that obtains current in- Glasgow et al., Ann Behav Med 2002 24(2): 8087formation on patient status regard-ing multiple health behaviors. Basedon the patient’s risk profile com- a mutually negotiated, achievable,bined with information on behavior, and specific plan) then follows. Thefamily history, personal beliefs, and planning should include assistanceany other available data, the health with problem-solving, identifyingprofessional then provides clear potential barriers or challenges toand specific, personalized advice achieving the previously identifiedto change one or more behaviors. goals and generating solutions toIt is important that this advice be overcome them. The final “A” (“ar-provided in an interactive manner range”) refers to the setting up ofthat includes a discussion of what follow-up support and assistance.the patient thinks and feels about While this aspect of the behaviorthe health professional’s advice change model is often omitted, it isand recommendations. A collabora- essential for long-term success.tive goal-setting process (agree on Stand-alone self-management sup- 31
  31. 31. port formats such as health worker– week, over six weeks. The programled group visits and peer-led self-man- includes training in cognitive symp-agement programs can be used to tom management and methods forcomplement the 5As approach. managing negative emotions (e.g., Health worker–led groups typi- anger, fear, depression, and frustra-cally convene patients who share a tion) and discussion of topics suchsimilar health problem together with as medications, diet, health carea health worker or team. Formats workers, and fatigue. Lay leadersvary but generally allow patients teach the courses in an interac-to obtain emotional support from tive manner designed to enhanceother patients and learn from their participants’ confidence in theirexperiences while also receiving ability to execute specific self-careformal education and skills training tasks. The goal is not to providefrom health workers. Group visits disease-specific content but rath-offer many advantages over tradi- er to use interactive exercises totional one-to-one visits with health build self-efficacy and other skillsworkers (66). They make more effi- that will help participants bettercient use of health workers’ limited manage their chronic conditionstime; allow for more detailed provi- and live an active lifestyle. A vitalsion of information; facilitate peer element is exchange and discus-support from patients facing similar sion among participants and withself-management challenges; and peer leaders. The CDSMP has prov-facilitate the participation of fami- en to be effective (55). The CDSMPlies and other types of health care has recently incorporated an onlineprofessionals. training program. Similarly in the Some programs use peers (rath- United Kingdom, the Expert Patienter than health workers) as educa- Program is a self-management ini-tors and trainers. Peers are thought tiative led by trained lay people withto be especially effective as leaders experience in long-term conditions.because they serve as excellent role The program is designed to enablemodels for participants. Many peer- participants to develop appropriateled programs around the world are self-care skills(68). An evaluationmodeled on the principles and for- found that the program was effec-mat of Stanford University’s Chronic tive in improving self-efficacy andDisease Self-Management Program energy levels among patients with(CDSMP) (67). The CDSMP is admin- long-term conditions, and was likelyistered in 2.5-hour sessions, once a to be cost effective (56). 32
  32. 32. The Chronic Care PassportRegion of the (69) is a patient-held card usedAmericas: by patients with CNCDs such as diabetes, hypertension, andThe Chronic COPD. The Passport includes pre-Care Passport vention advice on nutrition, physical activity, and toxic habits as well as pre- ventive measures for cervical, breast, and prostate cancer. It also contains a summarized meal plan with a food exchange list. The Care Plan shown on the Passport’s central page itemizes a completelist of laboratory tests, health exams, and self-management educa-tion issues for the main chronic diseases (i.e., diabetes, hypertension,hypercholesterolemia, and obesity). The Care Plan lists a series ofclinical standards from international evidence-based guidelines andprotocols for all enumerated laboratory tests and exams, includingthe total cardiovascular risk evaluation. The Passport has spaces forestablishing targets with patients and recording the results obtainedduring different patient visits. It was designed for the PHC level butcan be used or adapted to other settings. The Passport is one of theproducts of PAHO’s technical collaboration with various memberstates and it is accompanied by two additional materials: The HealthProvider and the Patient brochures.As of May 2012, demonstration projects have been established in 13countries throughout the Region. The Passport is being implementedin Antigua, Anguilla, Argentina, Belize, Chile, the Dominican Re-public, Grenada, Honduras, Jamaica, Paraguay, Santa Lucia, Surina-me, and Trinidad and Tobago.Source: Reference (69). 33
  33. 33. EXPERIENCE SHOWCASE Caribbean: Improving Quality of Chronic Care in the Caribbean (Antigua, Anguilla, Barbados, Belize, Guyana, Grenada, Jamaica, St. Lucia, Suriname, and Trinidad & Tobago) The CCM is being implemented in 10 Carib- bean countries (142 centers providing care for more than 40 000 patients). The objective of Caribbean Quality of Diabetes Care Improvement Project is to strengthen the capacity of health sys- tems and competencies of the workforce for the integrat- ed management of chronic diseases and their risk factors. The project promotes the integrated management of chronic diseases with a preven- tive focus, based on equity, the participation of the individual, his or her family, and the community. The evaluation of this demonstration project included 1,060 patients with diabetes using the Chronic Care Passport at the first level of care in eight countries. Preliminary results are prom- ising. Comparing baseline to follow-up measures revealed an important decrease in mean HbA1c (8.3% to7.6%). There was also a substantial increase in the proportion of patients with a preventive practice, such as nutritional advice (12% to 52%), foot exam (28% to 68%), or eye exam (21% to 61%). Overall the proportion of patients meeting three or more quality-of-care indicators increased from 12% to 56%. Source: Reference (70). Chile: Tele-Care Self-Management Program in Santiago The prevalence of diabetes in Chile increased from 4.2% to 9.2% between 2005 and 2010. The increased demand for better care for people with type 2 diabetes and the needs for improv- ing the efficacy of the health system prompted a group of researchers from the Catholic University of Chile to create a self-management service using cellular phones. A program of telephone counseling called ATAS (from the Spanish Apoyo Tecnológico para el Automanejo de Condiciones Crónicas de Salud ) was added to usual care for people with type 2 diabetes in a low income area of Santiago de Chile. The ATAS model promoted active participation of patients and fam- ily caregivers in health-related decision making and fostered continuous contact between patients and the health care team. After 15 months of intervention the results indicated that patients receiving the intervention (n = 300) maintained blood sugar level, as measured by A1c before and after intervention, while an increase of 1.2% was recorded for patients re- ceiving usual care alone (n = 306) during the same timeframe. Other pos- itive results found, when comparing the group receiving the intervention to their peers receiving only usual care, were: an increase in attendance to medical appointments; a reduction in the number of emergency room visits; an increase in self-efficacy; and an increase in client satisfaction . Source: Reference (71). 34
  34. 34. Mexico: Unit of Medical Specialties (UNEMES) In response to the current epidemic of NCDs and obesity, the government of Mexico created the Units of Medical Specialties (UNEMES, form the Spanish Unidades de Es- pecialidades Médicas) in 2008. The UNEMES are clinics providing primary integrated care with an innovative ap- proach, to people with obesity, diabetes and cardiovas- cular risk. The UNEMES are financed by the popular insur- ance, which provide comprehensive integrated care to low income people (that are not otherwise covered by any program) in Mexico. The UNEMES initiative came from the Integrated HealthCare Model (MIDAS, from the Spanish Modelo Integrado de Atención a la Salud). TheUNEMES provide evidence based care that integrates multiple specialties. UNEMEShealth services are patient centered preventive services with emphasis on treatmentadherence, nutritional behavior, and physical activity for individuals and families.The UNEMES services include detection and integrated management of overweight,diabetes and cardiovascular risk, nutritional counseling, diagnosis of children andadolescent obesity and overweight, diagnosis of gestational diabetes, and detectionand management of complications of diabetes and hypertension. UNEMES’ staffincludes physicians, nutritionist, social workers, as well as information technologyand support personnel. Team members in UNEMES are trained to follow a standardnational protocol for NCD management.Source: Reference (72). Central America: The Central America Diabetes Initiative (CAMDI) Intervention (El Salvador, Guatemala, Honduras and Nicaragua) The CAMDI Intervention was a quality improvement collaborative project involving 10 health Centers and 4 hospitals from El Salvador, Guatemala, Hon- duras, and Nicaragua. During this 18 month inter- vention health teams selected their own objectives and activities and participated in three learning ses- sions with national and international experts. The ac- tivities of the CAMDI intervention included the review of national norms and protocols for the management of diabetes,training in diabetes and foot care education as well as the implementation of dia-betes clubs. A total of 1,290 patient participated in the intervention. The evalua-tion of 240 randomly selected patients indicated a reduction of the mean A1c frombaseline to the end of the intervention from 9.2% to 8.6%. Results also indicated re-markable improvements in process indicators, when comparing baseline to follow-upmeasures the proportion of patients with eye exam increased from 14% to 52%, theproportion of patients with foot exam went from 21% to 96% and the proportion ofpatients receiving diabetes education increased from 19% to 69%. The interventiondemonstrated that the quality of diabetes care can be improved when health teamsdedicate additional time to training in clinical care and patient education.Source: Barceló A, Pan American Health Organization (personal communication 2012). 35
  35. 35. 36
  36. 36. Delivery System DesignKEY ACTIONS FOR DELIVERY SYSTEM DESIGN Organize PHC based care; Define roles and distribute tasks among team members; Ensure proactive care and regular follow-up; Use risk stratification; Provide case management or a care coordinator for patient with complex diseases; Give care that patients understand and that conforms to their cultural background; Develop integrated health service delivery networks.EXAMPLE OF EFFECTIVE INTERVENTIONS Clinical record audit and feedback (73) Assigning a role in self-management, decision support and delivery system design to a designated clinical provider (74) Implementing a personalized structured discharge plan (75) Referral guidelines and forms (76) Using regular planned recall of patients for appointments (77) Chronic care management programs for diabetes (78) Program of nurses contacting frequently with patient (60) 37
  37. 37. R aising expectations for health systems without implementing specific changes is unlikely to besuccessful. The system itself must bemodified in terms of its delivery systemdesign, another component of the CCM. Improving the health of people phasize the importance of multidis-with CNCDs requires transforming ciplinary PHC that covers the entiresystems that are essentially reactive population, serves as a gateway to(responding mainly when a person the system, and integrates and co-is sick) to those that are proactive ordinates health care across levels,and focused on keeping a person in addition to meeting most of theas healthy as possible. Productive population’s health needs (40).interactions are made more likely by Patients with more complexplanning visits or other interactions conditions and/or care needs of-in advance and scheduling regular ten benefit from clinical case man-follow-up visits. agement services from nurse care Multidisciplinary teams are an- managers and outreach workers,other crucial component of effective who provide close follow-up andCNCD care and can include a wide help increase adherence (81-82).range of allied health professionals. Case management is often provid-Evidence indicates that non-physi- ed by a care coordinator. The carecian clinicians can function just as coordinator is responsible for iden-effectively as physicians (and some- tifying an individual’s health goalstimes better) within a supported and coordinating services and pro-context (79-80). viders to meet those goals. The IHSDNs (described above) pro- care coordinator may be a nursevide a good approach for redesign- care manager, a social worker, aing CNCD care. These networks em- community health worker, or a lay 38
  38. 38. person (83). Case management bya person other than the patient’s FIGURE 3. The Kaiser Permanente Risk PyramidPHC worker has also been shownto be effective in producing positive Population Managementhealth outcomes for people withchronic conditions (63, 84). More than Care & Case Management The Kaiser Permanente Risk Pyr-amid (85) (see Figure 3) has been Targeting Redesigning Measurement ofused in many countries to help Population(s) Processes Outcomes & Feedbackstratify people with CNCDs and pro-vide different levels of care. In thismodel, care is divided into three Level 3different levels. Level 1, which Highly Intensive complexcomprises about 70% –80% of the or Case memberclinical population, provides sup- Managementported self-care—collaborativelyhelping individuals and their care- Level 2 Assisted High riskgivers to develop the knowledge, Care or Careskills, and confidence to care for members Managementthemselves and their condition ef-fectively. Level 2 is designed forpatients who need regular contact Level 1with multidisciplinary team to en- Usual 70-80% of a Care withsure effective management (about Support CCM pop15% –20% of the clinical popula-tion). Disease-specific care man-agement provides people who havea complex single need or multipleconditions with responsive, special-ist services using multidisciplinary FIGURE 4. The Modified Kaiser Permanente Risk Pyramidteams and disease-specific proto-cols and pathways. Level 3 targetspeople who require more intensivesupport. This is the highest level Intensive Level 3of care. Care for Level-3 patients Case/Care Complex co-morbidityuses a case management approach Management 3 - 5% 5 Prto anticipate, coordinate, and link of Level 2 eshealth and social care. Disease/Care sio Management Poorly controlled The Kaiser Permanente Risk Pyr- n single condition alamid has been modified to address 15 - 20% Caissues such as population-wide reprevention, health improvement, Level 1and health promotion (see Figure Self Management Self-Management4). A second layer at the bottom 70-80% of LTCof the pyramid targets inequalitiesamong those at high risk for CNCD. Inequalities Targeted High Level ZeroThis layer is denominated level zero Risk Primary Preventionand is relevant to health services,so implementation of primary pre- Population Wide Prevention, Healthvention is recommended in clinical Improvement & Health Promotionsettings (86). 39
  39. 39. EXPERIENCE SHOWCASE United States: Focusing on those with Multiple Chronic Conditions In recognition of the prevalence, cost, and quality of life issues that affect U.S. citizens living with multiple chronic conditions (MCCs), the U.S. Department of Health and Human Services (DHHS), in concert with hundreds of external stakeholders, de- veloped a Strategic Framework on Multiple Chronic Conditions (www.hhs.gov/ash/initiatives/mcc/mcc_framework.pdf). This framework provides a road map to coordinate and guide national efforts aimed at improving the health of individuals with MCCs. Dis- seminated to the public in December 2010, the MCC Strategic Framework is designed to address the challenge of MCCs across the spectrum of all population groups through four main goals: 1. Fostering health care and public health system changes to improve the health of individu- als with MCCs; 2. Maximizing the use of proven self-care management and other services by individuals with MCCs; 3. Providing better tools and information to health care, public health, and social service workers who deliver care to individuals with MCCs; 4. Facilitating research to fill knowledge gaps about individuals with MCCs, and interventions and systems to benefit them. Within each of the four goals, the MCC Strategic Framework specifies multiple objectives and specific strategies. The strategies are designed to guide actions that can be taken by clinical and social service providers, public health professionals, and the public to prevent and reduce the burden of MCCs. Since the framework’s release, DHHS agencies and external partners have worked to align their respective programs, activities, and initiatives with and in support of the framework’s goals, objectives, and strategies. Over 100 such efforts are now being conducted. Examples of the framework’s impact include the numerous research grants and demonstration projects that focus on improving care for the MCC population; the new MCC quality measurement framework for health care; and the more than 100 000 people that have received self-management support through this program, which is modeled on the CDSMP). Source: Reference (87), and Parekh A, DHHS, United States of America (personal communication, 2012). Uruguay: Redesigning Health Care Delivery Uruguay’s health system has been caught off guard by the rapid- ly increasing prevalence of CNCDs. Its initial response consisted only of sporadic health promotion and prevention activities. More recently, it initiated a pilot program (“Previniendo”) for redesign- ing health care delivery through the strengthening of PHC. The program is currently established in three of the country’s 19 ad- ministrative regions, with 13 health centers covering a population of 113 000 patients. Routine screening is conducted for hyperten- sion, diabetes, overweight/obesity, and colon cancer. Early diagnosis facilitates patient care according to the level of risk and is informed by current practice guidelines. An information system is also in place. After less than one year of implementation, 12.6% of the target population has been screened and 16.7% of patients have been followed up. The program will be scaled up to other depart- ments, once successful results have been confirmed. Source: Solá L, Ministerio de Salud Pública, Uruguay (personal communication, 2011). 40

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