Apresentação realizada no I Seminário Internacional de Atenção às Condições Crônicas, pela diretora do Programa da Gestão de Doenças Crônica dos Serviços Sanitários De Alberta/Canadá, Sandra Delon. Belo Horizonte, 11 de novembro de 2014

1. CHRONIC DISEASE MANAGEMENT Case Study Calgary/Canada, 2002-2009
Belo Horizonte
November 11 -12, 2014

2. Where is Calgary ?

3. Rocky Mountains

4. Winter City

5. Hockey

6. Chronic Illness
•
“ Surveys across a variety of diseases including high blood pressure, diabetes, coronary artery disease, asthma and congestive heart failure have shown that 40 to 80 percent of patients are inadequately treated.”

7. Deficiencies include
•
Rushed providers not following established practice guidelines
•
Lack of care coordination
•
Lack of active follow-up to ensure the best outcomes
•
Patients inadequately trained to manage their illnesses

8. The System Needs to Change
•
Our health system is designed to manage acute illnesses, not manage (much less prevent) chronic ones
•
…and each system is perfectly designed to get the results it achieves
W. Edwards Deming, US Management Consultant, 1900-1993

9. World Health Organization

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Chronic Care in Calgary
To better address the problem of chronic disease, Calgary:

Formally began a Chronic Disease Program in 2002

Appointed a 1.0 Director and .5 Medical Lead

Targeted diabetes and hypertension

Provided project dollars

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Chronic disease management can’t be an add-on to someone’s current job
Key to Success

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Underlying Principles

Focus on secondary prevention

Use a ‘proven’ model of Chronic Care

Focus on building infrastructure rather than management of individual diseases

Be patient-centered and community-based

Work within existing operations

Be flexible with implementation

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Key to Success
At developmental stage need people who can think outside the box

15. Guiding Framework – Chronic Care Model
•
Developed in mid 1990s at MacColl Center for Health Care Innovation (Seattle)

Has been applied to a variety of chronic illnesses, health care settings and target populations

Shown to improve patient outcomes and reduce costs for many chronic conditions
www.improvingchroniccare.org

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Chronic Care Model
Productive
Interactions
Prepared,
Proactive
Practice Team
Improved Outcomes
Delivery System Design
Decision
Support
Clinical Information System
Self- Management Support
Resources & Policies
COMMUNITY
Health Care Organizations
Informed, Empowered Patient
HEALTH SYSTEM

17. Health System
Create a culture, organization and mechanisms that promote safe, high quality chronic care
–
All levels of the organization need to visibly support efforts to improve chronic illness care,
–
Develop agreements that facilitate care coordination within and across organizations

18. Delivery System Design
Assure the delivery of effective, efficient clinical care and self-management support
–
Define roles and distribute tasks among team
–
Use planned interactions to support care
–
Provide case management for complex patients
–
Ensure regular follow-up by the care team
–
Give care that patients understand and fits with their cultural background

19. Decision Support
Promote clinical care that is consistent with scientific evidence
–
Embed evidence-based guidelines into daily clinical practice
–
Use proven provider education methods
–
Integrate specialist expertise and primary care

20. Clinical Information Systems
Organize patient data to facilitate efficient and effective care
–
Provide timely reminders for providers and patients
–
Identify relevant subpopulations for proactive care
–
Facilitate individual care planning
–
Share information among providers to coordinate care

21. Self-Management Support
Empower patients to manage their health and health care
–
Emphasize the patient’s central role in managing their health
–
Use effective self-management support strategies that include goal-setting, action planning and problem-solving

22. The Community
Mobilize community resources to meet needs of patients
–
Encourage patients to participate in effective community programs
–
Form partnerships with community organizations to support and develop interventions that fill gaps in needed services

23. Key System Challenges facing Calgary

Variation in care

Lack of care coordination and follow up

Limited use of multidisciplinary team

Patients inadequately trained to manage own illnesses

Financial incentives did not support good chronic illness care

24. Developed Care Algorithms
–
Specified the care that was to be provided, by which provider, when and where

Developed for the key chronic conditions

All providers were involved

Led by medical specialists

Identified gaps in provider education

25. Assigned Multidisciplinary Teams to Support Family Physicians
–
Some team members co-located in doctor’s offices to follow up patients (eg nurses)
–
Others work in community settings to deliver patient education and provide supervised exercise programs (eg kinesiologists, physiotherapists, dietitians)
–
Medical specialists provide in-services and support for complex patients

26. Living Well Community Program
•
Living Well program provides:

Supervised exercise classes

Disease-specific education

Self-management classes

27. Aim of Program

Be accessible. Offered in community settings, e.g., gyms and community centres

Provide ‘one stop shopping’ for participants

Be sustainable – link with community organizations to expand reach

Be appropriate for people with a range of chronic conditions

28. Living Well Program
•
Agreements with other organizations to provide disease education classes at sites
•
Patients feel safe exercising as health professionals run class
•
Program provide social support to patients

29. Introduced Self-Management Training for Patients
–
Adopted the Stanford Chronic Disease Self- Management Program

Developed by Dr Kate Lorig in the 1980s at Stanford University (patienteducation.stanford.edu)

6 week program suitable for anyone with a chronic condition

Taught in small groups, by lay people

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Characteristics of Program
•Standardized training for leaders
•Highly structured teaching protocol
•Standardized participant materials
•Sesame Street approach

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Core Assumptions
•
Patients with different chronic diseases have similar self-management problems and disease-related tasks
•
Patients can learn to take responsibility for the day-to-day management of their disease(s)

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Core Assumptions
•
Trained lay persons with chronic conditions can effectively deliver a structured patient management/ education program
•Patient self-management education should be inexpensive and widely available

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Patients spend less than .1% of their time in the physician’s office
Time spent in doctor's office (0.07%) vs. Time in self- management (99.93%) (based on total of six hours per year) Self-ManagementDoctor Visits

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Introduced Care Plans
•
A way for providers and patients to work together to manage a patient’s chronic conditions
•
Care plans outline the patient’s goals, upcoming interventions and the role of all the providers involved in the care
•
Why is care planning important?
•
Takes focus away from disease to patient as a whole
•
Facilitates communication between patient and providers
•
Is motivational for patients
•
Integrates medical and self-management

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Evidence for Care Plans
•
Better clinical outcomes
•
Improved quality of life
•
Reduced hospital admissions, unplanned GP visits, emergency visits
•
Increased satisfaction with service
•
More efficient clinical practice
http://som.flinders.edu.au/FUSA/CCTU/contact.htm

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New Fee Code in Alberta for Family Physicians
•
03.04J Complex Care Plan – the development, documentation and administration of a comprehensive annual care plan for a patient with complex needs…$206.70 (Launched April 1, 2009)
•
Patients must have at a minimum, either:
•
2 from A; or
•
1 from A and 1 from B
Column A
•
Hypertensive Disease (ICD-401)
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Diabetes Mellitus (ICD-250)
•
COPD (ICD-496)
•
Asthma (ICD-493)
•
Heart Failure (ICD-428)
•
Ischaemic Heart Disease (ICD-413-414)
Column B
•
Mental Health Issues (ICD-290-319)
•
Obesity (ICD-278)
•
Addictions (ICD-303-304)
•
Tobacco (ICD-305.1)

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New Fee Code Launched April 1, 2009
Source: Calgary Herald, March 16, 2009

41. Monitor progress
Results

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Results – ACIC (Assessment of Chronic Illness Care)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
Mean Rating (0-11)
Literature (N=90) 2003 (N=27) 2007 (N=41)

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Results – HbA1c Control
0%
10%
20%
30%
40%
50%
60%
70%
80%
% < = 7 %
Baseline 12 – Months
All (N=5492)
Population
17% more patients with diabetes had blood sugar under control,
p < .001

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Results – Hypertension
10% reduction in blood pressure among those at higher risk, p < .001
100%
110%
120%
130%
140%
150%
160%
180%
Mean Systolic BP
Baseline 6 – Months
All (N=464)
170%
High Risk (N=115)
134
131
160
145
High risk = > 145 at baseline

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200
400
600
800
1000
0
300
500
700
900
Visits Per 1000 Patients
Baseline
12 – Months
All (N=17233)
Population
Results – ED Visits
ED visits dropped by 34%, p < .001

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Inpatient Admissions dropped by 41%, p < .001
50
150
250
350
450
0
100
200
300
400
500
Visits Per 1000 Patients
Baseline
12 – Months
All (N=17233)
Population
Results – Inpatient Admissions

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Bed days dropped by 31%, p < .001
Visits Per 1000 Patients
Baseline
12 – Months
All (N=17233)
Population
0
1000
2000
3000
4000
6000
5000
Results – Bed Days

48. Key to Success
•
Paradigm shifts take time

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Stay below the radar while testing different approaches and ideas
Key to Success

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At the Closing Bell…
‘ Progress is impossible without change and those who cannot change their minds cannot change anything ‘
George Bernard Shaw