Jan Van Emelen - MLOZ e-health


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Jan Van Emelen - MLOZ e-health

  1. 1. How can we use disease management forbetter coordinated healthcare interventions? The Disease Management Centre Jan Van Emelen & Irina Odnoletkova The Independent Health Insurance Funds 25.11.2010
  2. 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 2Réunion - Date
  3. 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 3Réunion - Date
  4. 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. 4Réunion - Date
  5. 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 5Réunion - Date
  6. 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 6Réunion - Date
  7. 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. 7Réunion - Date
  8. 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” 8Réunion - Date
  9. 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 GuidelinesB. Patient empowerment toolsC. Healthcare providers support - tools (IT based)D. Assessment : Medical - economic 9Réunion - Date
  10. 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 10Réunion - Date
  11. 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 11Réunion - Date
  12. 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 12Réunion - Date
  13. 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 13Réunion - Date
  14. 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 14Réunion - Date
  15. 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 15Réunion - Date
  16. 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 16Réunion - Date
  17. 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”. 17Réunion - Date
  18. 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! 18Réunion - Date
  19. 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 19Réunion - Date
  20. 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 20Réunion - Date
  21. 21. Chain of self-management support effect Patient Behaviour Disease Control Health Care Utilization Health Outcomes Patient Satisfaction Less Costs 21http://www.ahqa.org/pub/uploads/ptmgmt.pdfRéunion - Date
  22. 22. Coaching phases 1. Educatie 2. Empowerment 3. Action Plan 4. Monitoring tijdens het vervolgcontact 22Réunion - Date
  23. 23. Zorg TV Partners 23Réunion - Date
  24. 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. 24Réunion - Date
  25. 25. Coaching phases 1. Education 2. Empowerment 3. Action Plan 4. Monitoring 25Réunion - Date
  26. 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 26Réunion - Date
  27. 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 27Réunion - Date
  28. 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 28Réunion - Date
  29. 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. 29Réunion - Date
  30. 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. 30Réunion - Date
  31. 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. 31Réunion - Date
  32. 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 32Réunion - Date
  33. 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 33Réunion - Date
  34. 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 34Réunion - Date
  35. 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. 35Réunion - Date
  36. 36. Evidence-based medicine is offered in chronic disease management for the first time in the private system 36Réunion - Date
  37. 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; 37Réunion - Date
  38. 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. 38Réunion - Date
  39. 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). 39Réunion - Date
  40. 40. What is the evidence? Backed by 15 years of research 2 randomised controlled trials 4-year follow-up of the 2nd RCT
  41. 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. 41Réunion - Date
  42. 42. Applied to different diseases 42Réunion - Date
  43. 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 43Réunion - Date
  44. 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 44Réunion - Date
  45. 45. l’Union Nationale des Mutualités Libres regroupe :de Landsbond van de Onafhankelijke Ziekenfondsen groepeert :