1. How can we use disease management for
better coordinated healthcare interventions?
The Disease Management Centre
Jan Van Emelen & Irina Odnoletkova
The Independent Health Insurance Funds
25.11.2010
2. Who are the Independant health insurance funds?
1.975.201 members (30th of April 2010)
Permanent growth
Market share (Belgium) : 18,5%
Compulsory and complementary health insurance
Services of social economy
Information on health, healthcare and insurance
issues.
Union and 7 health insurance funds
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3. Our Values
Independent health insurance funds are
Independent and political neutral
Sceptical but constructive
Transparent
Dynamic and innovative
Rational and scientific
Competition but solidarity
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4. Our national initiative in disease management
Creation of consortium with 4 IT, 2 HC providers
and 2 HIF for professional setup of DM Programs
Planning of DMC : new company with 2 HC
providers and 2 HIF for operational delivering of
DM services.
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5. Our international initiatives
AIM - COCIR partnership - to be enlarged
AIM Working group Disease Management
Workshops
Study- Visits (17-18.03 2011 Odense)
Events - Presentation
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6. 1. Introduction: Chronic diseases anno 2010
(Cfr . Reinhardt Busse – European Observatory)
Burden :
Epidemiologic
Economic
How to tackle :
Prevention
Disease Management
Integrated care
Challenges
Technical innovation : Pharmaceutical, IT
Organisation innovation : model
Financing innovation: model with incentives
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7. Disease management: key elements
Comprehensive care: multidisciplinary care for
entire disease cycle
Integrated care, care continuum, coordination
of the different components
Population orientation (defined by a specific
condition)
Active client–patient management tools (health
education, empowerment, self-care)
Evidence-based guidelines, protocols, care
pathways
Information technology, system solutions
Continuous quality improvement
Source: Velasco-Garrido, Busse and Hisashige 2003.
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8. MLOZ experiences
Platforms for chronic diseases in the complementery
insurance, launched in 2005
Lessons :
HIF is not the place for medical follow-up !
Healthcare providers were not suficiently included
What did we do since?
International contacts : AIM, USA - Kaiser
Permanente, Israel- Maccabi, Holland – Meavita…
Pilot projects education-coaching “ZorgTV”
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9. 2. What do we want to launch?
New services in 4 domains of chronic care:
A. Enrolment system based on the risk stratification
and the Evidence Based Practice Guidelines
B. Patient empowerment tools
C. Healthcare providers support - tools (IT based)
D. Assessment : Medical - economic
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10. How to launch ?
Setup :
Consortium with 2 x 4 stakeholders
Priorities :
Coaching services
Personal health record
DMC creation of new structures
Not for profit organisation to get started
Cooperation of HIF, GP Cercles and Hospitals
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11. Activities of DMC
1. Care plans development – integration/relation other initiatives
2. Individual Care plan management
3. Education/coaching/monitoring for each pathology and combined
pathologies
4. Care plans IT support and maintenance
5. Promotion of care plans and IT support with physicians
6. Training of physicians in system use
7. Facilitating of medical telephone support to patients outsourcing
with Home Care/Call centre‟s
8. Data processing and analysis
9. System quality monitoring and care plans upgrading
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12. Disease Management Development Program
From Consortium to DMC
DMC Services
DMC DEVELOPMENT DMC OPERATIONS
DMC
Communication DMC DMC
DMC
Installation Operations&
Business
Negotiations Marketing
plan
plan
Consortium
DMC legal advise &
Foundation DM C
implementation
Consortium
P0: DMC operating
system
requirements
& architecture
Requirement Pre Project
Project Execution Delivery
Analysis conditions
P1: Tele-Coaching Service Dvpt
Market Launch
1st Q 2011
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13. Consortium Goals
1. Build a Disease Management System and
integrate the existing applications/ initiatives
into the system (focus on the selected
pathologies)
2. Facilitate political lobbying for the
implementation of this solution (financing/ legal
framework/ adoption by professionals and
patients)
3. Create Disease Management Company to bring
Solutions to the market
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14. Governance
Consortium Structure
Steering Groep Advisory Board
(CEO’s/staff of member organizations) (political opinion leaders)
Consortium Management Staff
(Project Managers) Office Manager
Financial Controller
Project Groups
Medical
IT
Business
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15. P0: DMC Enterprise Architecture
Business, System and Technical blueprints
DMC operating system requirements & architecture
Business architecture
• Strategy
• Medical-functional By
analysis
• Business analysis
Independent
System architecture
• Data
• Application Experts
• Infrastructure
• Integration
Technical
architecture
By
• Standards Consortium
• Services Partners
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16. Roadmap
Survey (30 opinion leaders Belgium) : positive
results, maturity of system?
Priorities of development 2011
Coaching services
Personal health record
Running
Legal aspects : privacy, accountability, IP
Business plan development
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17. 3. Coaching & ZorgTV : Experiences and
services
Experiences with pilotproject “zorgTV” for
education and coaching of diabetes type 2 patients
Development of coaching services with
“The Coach Program”.
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18. Diabetes Care in Belgium
Challenges of the educational concept
+/- 500.000 diabetics in Belgium;
50% are not aware of that
• Fragmented curative healthcare
Patient education :
Begins too late (for insuline-patients)
No national quality standard
Nurse travelling is timewaisting
Too much info at once for patient (totally: 3 till 5 hours)
Outdated concept!
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19. International trend in chronic care
90% of care = selfcare
Symptom monitoring + required actions (adjustment of
medications, doctor appointments);
Lifestile changes (e.g. stop with smoking, alcohol
consumption, diet and weight control, physical activities
guide);
Therapie compliance and monitoring of the treatment plan
=> new tools for selfmanagement support are
necessary aimed at patient behavioural change
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20. Self-management support
is “the systematic provision of education and
supportive interventions by health care staff to
increase patients‟ skills and confidence in
managing their health problems, including
regular assessment of progress and problems,
goal setting, and problem-solving support.”
http://www.ahqa.org/pub/uploads/ptmgmt.pdf
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21. Chain of self-management support effect
Patient Behaviour
Disease Control
Health Care Utilization
Health Outcomes
Patient Satisfaction
Less Costs
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http://www.ahqa.org/pub/uploads/ptmgmt.pdf
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22. Coaching phases
1. Educatie
2. Empowerment
3. Action Plan
4. Monitoring tijdens het vervolgcontact
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24. ZorgTV Project Goals
1. Test the feasibility of distant patient education and
coaching
2. Test the multidicsiplinary cooperation concept around
the patient in the first line.
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25. Coaching phases
1. Education
2. Empowerment
3. Action Plan
4. Monitoring
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26. Zorg TV Concept
20 diabetics type 2 selected by GP have received distant
nurse coaching during 6 months using the medium of their
own choice:
for communication: telephone, or video-phone,
for the videolibrary: DVD, or iDTV
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27. Video-library
12 modules/ 60 minutes of video-education
for patients with diabetes 2:
What is diabetes? – Why me? – Complication risks -
What can I do? – Healthy Eating Habits – Food atlas etc.
All validated by
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28. Self management support
of patients with CHD
The EUROASPIRE survey by the European Society of Cardiology (ESC)
was performed
1. 1995-1996,
2. 1999-2000, in nine countries
Conclusion: high rates of modifiable cardiovascular risk factors in
patients with coronary heart disease.
3. 2006-2007 in 22 countries,
Goal: to determine whether preventive cardiology had improved and
whether prevention guidelines were being followed.
http://www.theheart.org/article/947933.do
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29. Risk factors across the EUROASPIRE surveys
EUROASPIRE
Risk factor I (%) II (%) III (%)
Smoking 20.3 21.2 18.2
Overweight and obesity 76.8 79.9 82.7
Obesity 25.0 32.6 38.0
Elevated blood pressurea 58.1 58.3 60.9
Elevated cholesterol levelsb 94.5 76.7 46.2
Reported diabetes mellitus 17.4 20.1 28.0
•a. Elevated blood pressure is defined as 140 mm Hg or more systolic or 90 mm Hg or more diastolic for
those without diabetes and 130 or mm Hg or more systolic or 80 mm Hg or more diastolic for those with
diabetes
•b. Elevated serum total cholesterol was defined as >4.5 mmol/L (>175 mg/dL)
•Kotseva K et al. Lancet 2009; 373:929-940.
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30. Cardioprotective drug treatment across the
EUROASPIRE surveys
EUROASPIRE
Medications I (%) II (%) III (%)
Antiplatelet therapies 80.8 83.6 93.2
Beta blockers 56.0 69.0 85.5
All blood-pressure–lowering 84.5 90.6 96.8
drugs
All lipid-lowering drugs 32.2 62.7 88.8
•Kotseva K et al. Lancet 2009; 373:929-940.
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31. Conclusions from
the EUROASPIRE surveys (1)
No change in blood pressure control despite increased use of
anti-hypertensive medications
61% above therapeutic target (BP < 140/90 mmHg)
Continuing improvement in lipid control with increased use of
statins
42% above the 2003 therapeutic target (TC < 4.5 mmol/l)
Increasing prevalence of diabetes, both self reported and
undetected, and deteriorating therapeutic control
78% above the therapeutic target of < 7.0 mmol/l
Increased use of anti-platelets, beta- blockers, ACE/ARB‟s, statins
and diuretics with a lower use of CCB‟s.
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32. Conclusions from
the EUROASPIRE surveys (2)
Lifestyle of coronary patients is a major
cause for concern with no change in
prevalence of smoking and continuing
adverse trends in prevalence of obesity and
central obesity
http://www.medicalnewstoday.com/articles/142222.php
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33. Conclusions from
the EUROASPIRE surveys (3)
Why is there a treatment gap?
3 possibilities:
1. The patient may not attend the doctor.
2. Patients attend the doctor but do not adhere to the
treatment.
3. Doctors may not make the appropriate checks or tests,
may not initiate the treatment or titrate therapy to the
dose required to achieve the target level.
=> need of patient coaching programs
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34. ZorgTV Lessons for upscaling
Use of special devices (digibox, videophone) is a costdriver to the
project.
Inspite of the free installations, the new devices were refused by
65% of patients.
Telephone coaching was generally well accepted.
The personal contact with the coach can not be replaced by
informational materials, e.g. the video-library.
A video-library is a good support but should be refreshed
regulary.
II
Consider personal medium choice of patients. Start with
telephone as an universal and payable communication tool
between the coach and the patient
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35. ZorgTV Lessons for upscaling
• Patient recruitment by GP‟s worked disappointingly slow.
• Telephone recruitment by a trained contactpersoon was succeful.
= Centrally organized patient enrolment with feedback
administration is recommended. GP should be informed.
• Administration and reporting on paper is inefficient and makes
comparable analysis difficult. = Use of a backoffice software
program for patient administration and reporting is recommended.
• No effect analysis was possible through the small scale of the
project . = A healtheconomic study is recommended. The study
design should be considered by software configuration.
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36. Evidence-based medicine is offered in
chronic disease management for the first
time in the private system
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37. Why The COACH program?
Uses national/European guidelines for treatment and
medications
Is executed by dietitians or health professional coaches who
train the patients in pursuing the target levels for their
particular risk factors while working with their usual doctor(s).
Has been selected by McKensey Consultancy as the best
evidence-based program;
Has been implemented in NL by Achmea for patients with
CHD;
Offers combination of internet-based software for nurse
administration and decision support, and coach training
concept;
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38. How does The COACH Program work?
The coach monitors:
1) The biomedical risk factors : fasting lipids (total cholesterol,
triglycerides and LDL-cholesterol); blood pressure; fasting
glucose or HbA1c.
2) Five lifestyle/behavioural risk factors: smoking; nutrition;
alcohol; physical activity; weight management.
For patients with diabetes and/or high blood pressure kidneys checks are
recommended: Albumin creatinine ratio, serum creatinine, estimated
glomerular filtration rate (eGFR).
For patients with diabetes: eye checks and feet checks are recommended.
3) Use of the recommended medications.
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39. Patients trained to take ‘ownership’ of their
health; self-manage their health
Coaching trains patients to
„drive‟
the process of achieving and
maintaining the target levels for their
risk factors while working in
association with their usual doctor(s).
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40. What is the evidence?
Backed by 15 years of research
2 randomised controlled trials
4-year follow-up of the 2nd RCT
41. 4-YEAR FOLLOW-UP OF THE COACH
STUDY MULTICENTRE RCT
Vale MJ, Sundararajan V, Jelinek MV, Best JD. Oral presentation at
the 77th Scientific Sessions of the American Heart Association,
November 7-10, 2004, New Orleans, Louisiana, USA. Circulation
2004; 110: Suppl: III-801
RESULTS
4 PHONE COACHING SESSIONS OVER 6 MONTHS (TOTAL OF 2 HOURS OF
COACHING TIME)
reduced hospital admissions by 16% (p<0.01)
reduced bed-days by 20% (p<0.001)
compared to usual care within 4 years after randomisation.
The savings started at 1 year and increased incrementally over 4 years.
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43. Funded by
State Health Departments
in ALL Australian States
VIC, SA, Hunter (NSW), WA, TAS, QLD
CHD, heart failure, diabetes,
pre-diabetes, high risk of diabetes, COPD
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44. Belgium: Healthcare needs innovation
Shared ZorgTV Partners View:
Upscaling of distant coaching is desirable to support
the patient and the practice of GP‟s and nurses
Next steps:
• service upscaling, application for other pathologies
• healtheconomic evaluation and analysis on structural
reimbursement
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45. l’Union Nationale des Mutualités Libres regroupe :
de Landsbond van de Onafhankelijke Ziekenfondsen groepeert :
