HLN004 Lecture 5 - Chronic conditions management - Frameworks, approaches and strategies

Queensland University of Technology
CRICOS No. 00213J
HLN004 Chronic conditions
prevention and management
Chronic conditions management –
frameworks, approaches and strategies

CRICOS No. 00213Ja university for the worldreal
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What is chronic disease management?
• Systematic, coordinated clinical management
process to improve healthcare for people with CD
• Occurs across continuum of care
– Includes treatment & education
• Aims to improve quality of life & health outcomes &
reduce progressions/ complications of CD
– Maintains optimal functioning with most cost-effective
& outcome-effective health care expenditure

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Chronic Disease Management in
Australia
• Reactive and acute focus  one that is proactive and
supports the management of chronic disease across the
disease continuum
– Includes the coordination of health care, pharmaceutical or social
interventions
– Designed to be cost effective and improve health outcomes
• Systematic approach across levels (individual,
organisational, local and national)

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Copyright ©2004 BMJ Publishing Group Ltd.
Models for chronic disease management - The Chronic Care Model (CCM)
Wagner et al, 1999 in Barr V, Robinson, Martin-Link & Underhill

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• Delivery System Design
– Create teams with a clear division of labour
– Separated acute care from the planned care
– Planned visits and follow up are important features
• Self-management support
– Collaboratively helping patients and families to
acquire the skills and confidence to manage their
condition
– Provide self management tools, referrals to
community resources and routinely assessing
progress
Elements of the CCM

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• Decision Support
– Integration of evidence based clinical guidelines into
practice and reminder systems
• Clinical Information Systems
– Reminder system to improve compliance with
guidelines, feedback on performance measures and
registries for planning the care for chronic diseases
Elements of CCM

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• Community Resources
– Linkages with hospitals providing patient education
classes or home care agencies to provide case managers
– Linkages with community based resources- exercise
programs, self help groups and senior centres
• Health Care Organisation
– The structure, goals and values of the provider
organisation. Its relationship with purchaser, insurers and
other providers underpins the model
Elements of CCM

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Models for chronic disease management - Innovative
Care for Chronic Conditions (ICCC Framework)
• Expansion of the Chronic Care Model
• Provides roadmap for improvement of health
system’s capacity to manage chronic conditions
• New expanded framework is comprised of
fundamental components within the levels of
patient interactions, organisation of health care,
community and policy.

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ICCC
The organisation of health care systems and how they
contribute to CDM is discussed in terms of:
• Macro Level
– governments developing and implementing policies to
prevent and manage chronic disease. Avoid
fragmented financing of project and improve
monitoring and regulations
• Meso Level
– systems to manage care over time. This will include
education of health professionals, evidence based
guidelines, prevention strategies, information systems
and linking with community resources.
• Micro level
– individuals develop skills to prevent and manage their
own health

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WHO, 2002

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How are Chronic Diseases Managed
Across the world?
From Zwar’s systematic review

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USA
• No national health care system
• Series of health care providers operating in a market
based system
• Funded on 3 levels:
- Government (Federal and State) funds Medicare for over
65 years and Medicaid for low income earners
- Employers through corporate membership of health
insurance
- Private individuals
• Focus on acute services
• Have adopted CCM
• Poor primary health care system

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USA
• Access to health care is inequitable
• Approx. 18% of population have no health insurance
– Many with low income and have a higher prevalence
of chronic disease
– unlikely that those individuals that have more than
one chronic disease have access to health insurance
and health care
• Groups such as the Veterans Affairs and certain
Managed Care organisations such as Evercare and
Kaiser Permanente have introduced intervention
programs based on CCM
– All have had positive outcomes
• USA still lags behind Europe in the management of CD

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Canada
• Health Care is run by each province rather than a
national system
– Publicly funded system, free at point of use
• CCM expanded to incorporate population health
promotion to prevent chronic disease
• Many of the expanded initiatives that have been
developed as part of the expanded CCM are
supported by the Primary Health Care Transition
fund
• Vancouver Island Chronic Illness program designed
to improve chronic care for the First Nation People

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United Kingdom
• The National Health Service is funded by the
tax system, access is free
• Strong focus on primary care
– Rewards to GPs for good chronic care
– National Service Improvement Frameworks for
each of the major chronic diseases

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United Kingdom
• Primary care for chronic disease includes
management using guidelines and have
specialised clinics which are separate from
acute care services
– National Institute for Health and Clinical Excellence
(NICE) has produced disease specific guidelines -
used as national standards of care
• Practice nurses play a major role in chronic
disease management – assist GPs in reaching
target goals

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New Zealand
• Care Plus – service for people with chronic
disease
– delivered through Primary Health Organisations
• Aim was to identify people with chronic disease
who required intensive case management
• Chronic care model has been developed in
South Auckland.
– Effective in improving patient outcomes for diabetes
– Address inequalities in health and patient follow up

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Chronic Disease Management in
Australia
• Australia has developed its management of chronic
disease on the Chronic Care Model and the Kaiser
Permanente model
Level 1: 70-80% of the chronic care
population can manage their own condition
Level 2: High risk patients benefit from
multidisciplinary CDM using clinical
pathways and protocols with care planning,
patient registries and shared electronic
health records
Level 3: Highly complex clients with co-
morbidities or other factors greatly benefit
from case management
(National Health Priority Action Council, 2006, p. 4)
Kaiser Permanente model

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Chronic Disease Management
Patients have chronic condition
under reasonable control and
receive care through their primary
health care team
– Priority - failure to improve
threatens population wide
improvements in chronic
disease prevalence and
management
Patients have poorly
controlled conditions
Patients with complex multidiagnoses,
high use patients who receive case
management by registered nurses or
medical personnel

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National strategic policy approach to
chronic disease prevention & care
• Two approaches
1. National Chronic Disease Strategy
– Overarching framework of national direction
2. Five supporting National Service Improvement
Frameworks
– Address key health priority areas
– Asthma; cancer; diabetes; heart, stroke & vascular
disease; osteoarthritis, rheumatoid arthritis &
osteoporosis
http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/48390/Connecting_Care_Full_Version_web.pdf

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National Healthcare Agreement (NHA) 2011
• Provides for integrated approach to improving
health outcomes for Australians and the
sustainability of the health system
• Defines the objectives, outcomes, outputs and
performance measures, and clarifies the roles
and responsibilities that guide the
Commonwealth and States and Territories in
delivery of services across the health sector

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National Health Care Agreement 2011/12
• This National Healthcare Agreement affirms the agreement of
all governments that Australia's health system should:
– Be shaped around the health needs of individual patients,
their families and communities;
– Focus on the prevention of disease and injury and the
maintenance of health, not simply the treatment of illness;
– Support an integrated approach to the promotion of
healthy lifestyles, prevention of illness and injury, and
diagnosis and treatment of illness across the continuum of
care; and
– Provide all Australians with timely access to quality health
services based on their needs, not ability to pay,
regardless of where they live in the country.

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Objectives of the HCA
• Prevention
– Australians are born and remain healthy
• Primary Care and Community Health
– Affordable and quality care
• Hospital and related care
• Aged care
• Patient experience
• Social inclusion and indigenous health
• Sustainability

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Outcomes
and
output
measures

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Health Funding
• The Australian Health Ministers' Conference
(AHMC) is the peak consultative body between
Commonwealth and states/territories
• Major health funding agreements are bilateral
agreements between the Commonwealth and
each State and Territory
– Strategic public health and other partnerships are
negotiated in similar ways.

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Australian Health Care System
• Universal access to health care via Medicare
Insurance
– Financed from general taxation revenue – 1.5%
taxable income
– Levy contributes ~27% of Medicare funding, so must
be topped up with other taxes
• Medicare provides for
– Subsidised prescribed medicines, provided by
doctors, dentists and optometrists
– Substantial grants to State and territory govts to run
public hospitals

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Health services delivery
Aged care is structured around 2 main forms of care delivery
1. Residential (accommodation and various levels of
nursing and/or personal care) – mainly non-govt sector
– financed by Commonwealth and the places available
are also specified.
2. Community care - provided jointly by Commonwealth
and State to enable older people to remain in their own
homes as long as possible
– (delivered meals, home help, transport) – both public
and non-govt usually charitable or religious support

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Private Health Care
• Private patients in private hospitals charged fees
by doctors and some allied health staff
• Billed for accommodation, nursing care and
other hospital services such as operating
theatres and radiology and pathology services
• Private health insurance covers some/all costs
– Some costs may be covered by Medicare

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Health services delivery
• Mix of public and private
– quality is high
• Large urban public hospitals provide most of the
more complex type of hospital care – intensive
care, major surgery, organ transplant, renal
dialysis and specialist outpatient services
– Most acute care beds and emergency outpatient
clinics are in public hospitals.

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Australian Healthcare System

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The Australian health system is a sophisticated
public-private and federal-state blend
Public
hospitals
Private
hospitals
CONSUMERS
Out of pocket
AUSTRALIAN
GOVERNMENT
STATE /TERRITORY
GOVERNMENT
Taxes &
levies
(including
Medicare
Levy)
MBS PBS PHI rebates
Community
health
Ambulance
services
(some states)
Aboriginal Medical
Services
Research
GPs&
specialists
Allied
health
Pharm
-acists
Rural Grants
Programs
Public health
programs
Taxes
and
levies
Private health insurers
Privately
supplied
goods
and
services
KEY
Payment by consumers
Payment by gov't and/or
private sector
Source: Schematic courtesy of Australian Department of Health and Ageing Available at: http://www.australia2020.gov.au/topcis/docs/health/ppt
This gives rise to a mixed model of
service provision and accountabilities

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Current health funding remains overwhelmingly focused on
treatment
1. Includes Commonwealth, State and local governments 2. Includes private health insurance funds, injury compensation insurers, and private individuals 3. Includes public and
private hospitals and patient transportation
Source: AIHW, National health expenditure 2005-6 (AIHW data cube)
National health expenditure, by area of expenditure – Australia: 2005/6 ($ per capita)
1,579
Hospitals
694
Pharma-
ceuticals,
aids and
appliances
754
Medical
services
Dental
services
148
Other health
practitioners
315
Capital
expenditure/
tax
261
Public and
community
health
121
Admin
93
Research
4,224
Total
Non-government
Government
259
Public/community health
represents just over 6% of total
expenditure

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Australia spends an average amount on health compared to
other OECD countries
Per capita expenditure ($USD) (left hand axis)
Health expenditure as % GDP (left hand axis)
Health expenditure - OECD countries: 2004 (US$ per capita, % GDP)
Source: OECD, Health Data 2007
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
0
5
10
15
20
Korea
Hungary
CzechRepublic
Portugal
Spain
NewZealand
Finland
Japan
Italy
UnitedKingdom
Greece
Ireland
Sweden
Denmark
Netherlands
Mexico
Canada
Germany
France
Belgium
Iceland
Austria
Switzerland
Norway
Luxembourg
UnitedStates
Turkey
Poland
GDP (%)Per capita (US$)
SlovakRepublic
Australia

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Health outcomes are significantly worse for low socio-
economic groups, rural and indigenous communities
Low socio-economic groups Rural and regional Australians Indigenous Australians
Burden of disease,
by SES quintile – Australia: 2003
Burden of disease,
by regionality – Australia: 2003
Years of life lost (YLL)
Years lost to disability (YLD)
1. Disease Adjusted Life Years (years lost through death by disease, and years lost to disability by disease)
Source: AIHW, The burden of disease and injury in Australia 2003 (2007); Vos, Barker et al, Burden of Disease and Injury in Indigenous Australians 2003 (University of Queensland,
2007)
Burden of disease, Indigenous
Australians by sex: 2003
For more on Indigenous health
and disadvantage, see The Future
of Indigenous Australia
For more on social disadvantage, see
Strengthening Communities... (p11-15)
0
50
100
150
200
250
144
Low
142
Mod.
low
140
Aver-
age
124
Mod.
high
115
High
DALY per 1,000 population (years)1
0
50
100
150
200
250
127
Major cities
144
Regional
134
Remote
0
50
100
150
200
250
187
Male
217
Female
This is a disease burden
2.5 times greater than a
non-Indigenous population
of the same age profile

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Lifestyle risk factors are also more prevalent in these
disadvantaged sectors of society
Low socio-economic groups Rural and regional Australians Indigenous Australians
1. Refers to Indigenous persons in non-remote areas, according to 2001 National Health Survey 2. Note that non-Indigenous statistics are age-adjusted, to represent estimate for a non-Indigenous population of
similar age/sex profile. Therefore figures for non-Indigenous population may not align exactly with absolute figures for overall population by SES or regionality
Source: ABS, 4364.0 National Health Survey: Summary of Results 2004-5 (2006); ABS, 4364.0 National Health Survey: Summary of Results 2001 (2002)
Prevalence of selected health risk factors,
top and bottom disadvantage quintiles
2004-5
Prevalence of selected health risk
factors, by regionality 2004-5
Prevalence of selected health risk
factors, by Indigenous status 2001
For more on social disadvantage, see
Strengthening Communities... (p11-15)
For more on Indigenous health and
disadvantage, see The Future of Indigenous
Australia
0
20
40
60
80
100
(% population)
Bottom quintile
Top quintile
Dailysmoking
Riskyalcohol
consumption
Sedentary
activity
Overweight
orobese
<1servefruit
<4servesveg
0
20
40
60
80
100
Outer regional/remote
Metropolitan
Inner regional
(% population)
Dailysmoking
Riskyalcohol
consumption
Sedentary
activity
Overweight
orobese
<1servefruit
<4servesveg
0
20
40
60
80
100
Indigenous1
Non-indigenous2(% population)
Dailysmoking
Riskyalcohol
consumption
Sedentary
activity
Overweight
orobese
<1servefruit
<4servesveg

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Outer regional
Major city
Inner regional
Remote/very remote
Access to health services also varies significantly
across communities
Access to health professionals varies widely As do the social barriers to health treatment
1. Based on numbers of people employed, not FTE. 2. As at December quarter 2007 (PHIAC) 3. As at 2004 (ABS)
Source: Most recent data on health practitioners provided by Federal Department of Health and Ageing; figures available on request. Private Health Insurance Administration Council (PHIAC), Quarterly
Statistics, December 2007; ABS, 1301.0 Year Book Australia 2006; ABS, 2068.0 Census Data 2006; AIHW, Male consultations in general practice in Australia 1999-2000 (2003); Klimidis et al, Mental Health
Service Use by Ethnic Communities in Victoria, 1995-6 (VTPU, 1999)
Private health insurance
• 45% of Australians have private health insurance2
• In addition to offering greater choice of health
provider, these insurers help to cover the ~15% of hospital
services with "gap" payments not covered by Medicare
Labour force barriers
• It is estimated ~25% of the working population is employed
on a casual basis3
• Where employment status does not include the right to
paid sick leave, there may be an economic disincentive for
taking time out of work to seek medical treatment (over and
above the cost of treatment itself)
Education and language barriers
• ~15% of Australians speak a language other than English at
home and ~3% of Australians speak English only poorly or
not at all
• A Victorian study indicated that people who prefer to speak
a language other than English are significantly under-
represented in obtaining mental health services, both
community-based and inpatient
Social stigma
• A 1997 survey suggested that nearly 70% of people with
mental health issues did not seek treatment – social stigma
is thought to be a major contributor
• A 2000 study found that almost 1 in 4 Australian men had
not seen a GP in the previous 12 months (compared with 1
in 10 women)
For information on access to
other services in rural and
regional areas, see The Future of
Regional Australia (p7-8)
71
88
121
205
475954 385236
113
2430
18
97
128
0
1,000
1,200
200
800
Health practitioners per 100,000 population, by regionality: 2005-06 (# )1
GPs Specialists Pharmacists Physio-
therapists
1,009
1,090
917
736
Nurses
(all types)

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The Australian medical workforce will face many challenges
in meeting future demand
The medical workforce is growing,
but GPs only just meet population
growth
We rely heavily on overseas-
trained health professionals
Our future workforce will have
to flexibly meet community needs
A strong base of national information
will be central to effective workforce planning
1. Refers to country of first qualification 2. This is an increase from 14% and 36% respectively in 2001
Source: AIHW, Medical Labour Force 2005 (2008)
% medical practitioners by place of
qualification
and citizenship status of overseas
qualified, 2005
Medical practitioners per 100,000
population, Australia 1999-2005
An increasing number of medical
practitioners are working part
time, especially women
• 15% of men and 38% of women work
less than 35 hours per week2
Many practitioners operate across multiple
clinical settings
• In 2005, practitioners worked in an
average of 1.2 settings (private practice)
or 1.3 settings (public practice)
Recent reforms to the health workforce have
seen some roles and responsibilities expand
to cope more flexibly with population
demand
• The introduction of Nurse Practitioners
allows them to perform some duties
previously reserved for GPs e.g.
prescribing medicine/ordering tests –
particularly important in remote areas
• Recent changes to the Medicare
schedule allow longer GP consultations
for managing mental illness/chronic
disease
0
100
200
300
163
2001
112 111
2000
164
185
2005
Other
practitioners
GPs
2004
180
109
2003
110
Practitioners per 100,000 population (#)
111
2002
172
110
1999
156 157
109
Overseas
Trained1
21%
Australian
Trained1
79%
Citizen
11%
69%
Temporary
Resident
Permanent
Resident
Residence
Status
20%
Of
which...

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Self-
Management
An integrated approach to electronic health record management
and information sharing has potential to help all players in the
healthcare sector
Providers
Administrators
Researchers
Policy-
makers
Funders
Patients
• Fuller patient information (especially when patient
is incapable of providing it) enables more informed
and efficient clinical decisions, improved risk
management, and avoids unnecessary
procedures/tests
• Funders can connect immediately to providers to
make real-time coverage, approval and payment
decisions
• Administrators have better demand information to
make more efficient and effective use of resources
• Policy-makers can gather better data to understand
and manage demand, and to direct resources
towards interventions which produce the most
effective
health outcomes
• Researchers may access more comprehensive
data, to more effectively analyse disease pathways
and the effectiveness of interventions
• Patients – particularly those with chronic diseases
– can take more ownership of their own medical
information, assisting self-management. They can
simplify their interactions with payers/providers
and
reduce duplication
There is opportunity to improve future productivity through
new systems and approaches to care
Electronic health infrastructureEvolving modes of care/clinical delivery
In the context of chronic disease, communities, healthcare
practitioners and individuals will have increasingly interconnected
roles in the management of population health
• Public screening/
new vaccinations
• Community
campaigns to
reduce lifestyle risk
behaviours
• New approaches to
education and
reduction of risk
factors in children
• New approaches
to developing
long-term
management
plans in
consultation with
primary
healthcare
providers
• Increased
powers of non-
acute carers to
manage chronic
conditions
• Greater
integration of
allied and
community
health
professionals in
ongoing disease
management
Medical
Treatment
Prevention
• New tools and
home-based
technologies for
self-monitoring
• Support for
carers in
managing health
of disabled
persons

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Settings and Providers for
Chronic Care
• Vast array of providers in a variety of settings
• Important that integration and coordination of
care occurs across all of these providers and
settings
• Kaiser Permanente model  majority of chronic
disease care required from community settings

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Medicare Items for managing chronic
disease
(2010)

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The item numbers and claiming
frequency
Name Item
no
Recommended frequency Minimum
claiming
period
Preparation of a GP
Management Plan
721 2 yearly 12 months*
Preparation of Team Care
Arrangements
723 2 yearly 12 months*
Review of a GP
Management Plan
732 6 monthly 3 months*
Coordination of a Review of
Team Care Arrangements
Contribution to a
Multidisciplinary Care Plan
Contribution to a
Multidisciplinary Care Plan
by an Aged Care Facility
*CDM services can be provided more frequently in ‘exceptional circumstances’.

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MBS Item 721 – GP Management
Plan (GPMP)
• For patients with a chronic (or terminal) medical
condition.
• Allow GPs to prepare care plans for eligible patients
where the involvement of other health or care providers
is not required.
– Patient assessed, management goals agreed, patient
actions identified, treatment and ongoing
management and documentation, review planned
• Regular reviews every 6 months

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MBS Item 723 – Team Care
Arrangements (TCAs)
• For patients with chronic or terminal medical conditions
who require ongoing care from a multidisciplinary team
– GP determines eligibility
• GP discusses/agrees with patient which providers should
be involved, what information can be shared, collaborates
with the participating providers, documents & sets review
date
• Can be provided without a GPMP
– To be eligible for Medicare rebates for the five individual allied
health services, a patient must be managed by a GP under both a
GPMP and TCAs.

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MBS Item 729 – GP contribution to
care plans
• For patients with a chronic medical condition having
multidisciplinary care plan prepared or reviewed for them
by another health or care provider.
• GP confirms patient’s agreement for the GP to contribute to
the plan, collaborates with the person preparing/ reviewing
the plan, including the GP’s contribution in the patient’s
records
– Eg. Hospital discharge planning

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MBS Item 731 – contribution to care
plans for residents of aged care facilities
• For GP to contribute to a multidisciplinary care plan for a
resident of an aged care facility
• Resident is eligible for Medicare rebates for up to five
individual allied health services and eight type 2 diabetes
group items each calendar year

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Advantages of CDM Items
• GPs are able to choose between items for GP
only care planning or for team-assisted care
planning
– Based on needs of patients
• Enhanced role for practice nurses and AHWs
• GPMP is widely accessible for patients with
chronic or terminal conditions
• Flexibility in claiming frequency
• Enables GPs to contribute to care plans
prepared for residents of aged care facilities

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Further information
• Key information is available at:
– www.health.gov.au (follow the A-Z index and ‘C’ for
‘Chronic Disease Management’)
– www.health.gov.au/mbsprimarycareitems
– Email inquiries: mbsonline@health.gov.au

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Chronic Disease Management
Workforce
• Today’s healthcare workers need a core set of
competencies that will yield better outcomes for
patients with chronic conditions
• A workforce for the 21st century must emphasise
management over cure and long term over
episodic care

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WHO’s Core Competencies
WHO undertook a review in 2005 and listed the
following as core competencies for patients with
chronic conditions:
– Patient Centred Care
– Partnering
– Quality Improvement
– Information and communication technology
– Public health perspective

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1. Patient Centred Care
• Interviewing and communicating effectively
• Assisting changes in health related behaviours
• Supporting self-management
• Using a proactive approach
2. Partnering
• Partnering with patients
• Partnering with other providers
• Partnering with communities
3. Quality Improvement
• Measuring care delivery and outcomes
• Learning and adapting change
• Translating evidence into practice
4. Information and communication technology
• Designing and using patient registries
• Using computer technologies
• Communicating with partners
5. Public Health Perspective
• Providing population-based care
• Systems thinking
• Working across the care continuum
• Working in primary health care-led systems
(Pruitt and Epping-Jordan, 2005)
Core Competencies as described by WHO

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Summary
No correct approach to chronic disease management
To be successful, policy makers should consider:
- Providing strong leadership and vision at the national,
regional or ogarnisational level
- Ensuring robust collection of information and data
sharing among all stakeholders
- Providing care based on people’s needs and an ability to
identify people with different levels of need;
- Targeting key risk factors, including widespread disease
prevention initiatives
- Supporting self-management and empowering people
with chronic diseases
(WHO, 2008, p. 1)

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References
• National Health Priority Action Council. (2006). National Chronic
Disease Strategy. Australian Government Department of Health and
Ageing, Canberra.
• WHO(2008). A framework to monitor and evaluate implementation.
• The Health of Queenslanders, 2010, 3rd report of the chief health
officer, www.health.qld.gov.au/cho_report.
• Pruitt, S. and Epping-Jordan, J. (2005). Preparing the 21st Century
global healthcare workforce. British Medical Journal. 330. 637-640.
• Zwar, N., Harris, M., Griffiths, R., Roland, M., Dennis, S., Davies, G.
and Hasan, I. (2006). A systematic review of chronic disease
management. Australian Primary Health Care Research Institute,
Sydney.

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HLN004 Lecture 5 - Chronic conditions management - Frameworks, approaches and strategies