Bang-on Thepthien Addiction Therapy 2015 Florida, USA August 03-08, 2015.

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Bang-on ThepthienAddiction Therapy 2015Florida, USAAugust 03-08, 2015

Chronic Care model and social protection: experience in ThailandDr. Bang-on ThepthienASEAN Institute for Health Development,Mahidol UniversityThailandTo introduce health care system in Thailand.To understand paradigm in health care in Thailand.Chronic care model and implementation in Thailand.Result.to point out possible directions to meet the challenge of caring for a growing population with chronic conditions.ObjectiveCharacteristics of Acute Care and Chronic Care

Characteristicsof Care TypeAcuteChronicAssistance and care: Maintain independent living, facilitate successful Goals of careCure: Restore to previous level ofpersonal and social adjustment, minimize further deterioration offunctioningphysical and mental health, and prevent acute exacerbations of chronic conditions

Specially trained health care andMultiple caregiver sources and settings, often includes a network ofProviders ofhuman services professionals incareinstitutions set up for acute carerelatives, friends, and community of services along with hospital,purposeshome health care, and social service professionalsScope of carePrimarily medical careBroad scope of social, community, and personal services, as well asmedical and rehabilitative careSignificant government investmentin outcome measures and quality ofRelatively few measures to assess quality of care provided by home Quality of carecare standards for most hospital-health agencies, community-based agencies, ambulatory clinicsbased acuteconditionsOrganizationsTypically occurs within oneMultiple organizations, requires organizational collaboration, may involved in careinstitutionintegrate primary care, acute care, and long-term care needsStaffs roleProvide medical careProvide medical care and Prepare patients to self-manage

Patients roleComply with the treatment planSelf-manage treatments, diet, medications, etc.

When health problems are chronic, the acute care practice model doesnt work.Bangkok83 community health care centers5Medical school hospitals19Specialized hospitals and institutionsRegional Level38 Specialized hospitalsProvincial Level77 General hospitals)52 Hospitals under Ministry of Defense9Hospitals BMAVillage Level834,711 Village Health VolunteersSub-district level9,791 Health center72,192 community PHC centersDistrict Level825 Community hospitals15 Municipal health centers365 Municipal health centers4 Hospitals under Ministry of DefenseOffice of the Permanent SecretaryDepartment of Medical service12 Mental Health HospitalsDepartment of Mental HealthDepartment of Health12 Regional Health centerMCHDrug AbuseCancerHeart, Skin, monk etc.7Medical school hospitalsHealth Delivery system in ThailandPARADIGM SHIFT IN HEALTH CAREFromToChronic DiseaseChronic conditions describes all health problems that persist across time and require some degree of health care management. Diabetes, heart disease, depression, schizophrenia, HIV/AIDS, substance use and ongoing physical impairmentsHospital basedPopulation focus ; Health care systems for chronic conditions are most effective when they prioritize the health of a defined population rather than the single unit of a patient seeking care. Population management is a long-term, proactive strategy in which resources are organized to improve quality of care and health outcomes in populations with well known and well understood medical service needs. This approach reduces the need for high cost, high intensity resources.Community basedCurePrevention focus :to reduce health risks, they are more likely to reduce substance use, to stop using tobacco products, to practice safe sex, to eat healthy foods, and to engage in physical activity.QuantityQuality focus :accountable for providing effective and efficient careSingleIntegration, coordination, and continuity across all categories of chronic conditions, moving beyond traditional disease boundaries.RoutineFlexibility/adaptability : surveillance, monitoring, and evaluation are key for systems to be able to adapt to changing contexts.Biomedical approachBio-Psycho-Social approachMedical Servicepublic health serviceCharacteristics of Acute Care and Chronic CareCharacteristics of Care TypeAcuteChronicGoals of careCure: Restore to previous level of functioningAssistance and care: Maintain independent living, facilitate successful personal and social adjustment, minimize further deterioration of physical and mental health, and prevent acute exacerbations of chronic conditionsProviders of careSpecially trained health care and human services professionals in institutions set up for acute care purposesMultiple caregiver sources and settings, often includes a network of relatives, friends, and community of services along with hospital, home health care, and social service professionalsScope of carePrimarily medical careBroad scope of social, community, and personal services, as well as medical and rehabilitative careQuality of careSignificant government investment in outcome measures and quality of care standards for most hospital-based acute conditionsRelatively few measures to assess quality of care provided by home health agencies, community-based agencies, ambulatory clinicsOrganizations involved in careTypically occurs within one institutionMultiple organizations, requires organizational collaboration, may integrate primary care, acute care, and long-term care needsDisease CenteredvsPatient Centered DiagnosisAnatomyPathologyDiseasePhysiologyIdea, ExpectationIllnessFunction IllnessFeeling, ConcernFamily, CommunityEnvironmentIncomeWork placeSub-optimal functional and clinical outcomesUninformed, passive patientsFrustrating, problem-centered interactionsRushed, unpre- pared, reactive Practice TeamCare delivery depends on MD only via short, unplanned visits and patient-initiated follow upNo care protocols; specialist input via traditionalreferrals onlyPatient information limited to what is in chart; no population- based data availablePatient problems in managing the condition not solicited or dealt with; counseling didactic onlyCommunity:No links w/community agencies or resourcesUsual CareModel:Health System:Leadership concerned primarily with the Bottom Line; incentives favor more frequent, shorter visits; no organized quality improvement processesTarget 1 A 25% relative reduction in risk of premature mortality from CVDs,cancer, diabetes, chronic respiratory diseasesTarget 2 At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national contextTarget 3 A 10% relative reduction in prevalence of insufficient physical activity Target 4 A 30% relative reduction in mean population intake of salt/sodium Target 5 A 30% relative reduction in prevalence of current tobacco use in personsaged 15+ yearsTarget 6 A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstancesTarget 7Halt the rise in diabetes and obesityTarget 8 At least 50% of eligible people receive drug therapy and counselling (including glycemic control) to prevent heart attacks and strokesTarget 9An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilitiesAchievement in 2025of 9 global targetsNCDs mortality, burden of disease and risksSource: modified from National Health Exam Survey IV 2010, and National Statistic Office 2009RISKMFTotalDataMortalityNCD mortality (thousand)161.3143.4304.72009% NCD to total mortality68.679.473.32009burden of diseaseDALYs (million)3.73.47.12009% NCD DALYS total67.780.473.32009disability-adjusted-life-year (DALY). This time-based measure combines years of life lost due topremature mortality and years of life lost due to time lived in states of less than full health.Prevalence of behavioral risksdaily smoker32.11.318.42010physical inactivity17.121.419.22010drinker51.08.830.02010Prevalence of physiological risksHigh bood pressure37.031.634.22010Hyperglycemia7.37.17.22010Overweight25.836.431.42009-10Obesity4.911.88.52009-10High cholesterol54.656.155.52010Wagners Chronic Care Model Demonstrates Best Practices in CDMWhat characterizes an informed, activatedpatient?Informed, Activated Patient

They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it.What characterizes a preparedpractice team?Prepared Practice Team

At the time of the interaction they have the patient information, decision support, and resources necessary to deliverhigh-quality care.Improved Functional and Clinical OutcomesInformed, Activated PatientProductive InteractionsPrepared Practice TeamHow would I recognize aproductive interaction?Delivery system designClear point of accessAssessment & care pathwaysCare plan /case managementFollow up and reviewCultural competencySelf-management supportCollaborative care planningSelf management support strategiesSelf management integrated intoservicesCapacity building of health professionalsDecision supportEmbed evidence-based guidelines into assessmentEmbed evidence-based guidelinesinto care plansIntegrate specialist & care primary expertiseClinical information systemShare information with providers tocoordinate careFacilitate individual patient care planningMonitor performance ofpractice team and care systemOrganize patient and population dataRoad Map212010201220142017Source: National Health Security OfficeDriven mechanism22System ManagerCase ManagerToolsNetwork Professional Association/ Academic organizationNetwork Club or society Local health fundsPrivate funds and supportSteering CommitteeNCD BoardSource: National Health Security OfficeCDMISNetworksPolicyOperationTechnocratMedResNet : Clinical dataMoPH : Epi. Surv. data BRFSS. MoPH/NHSO : Indiv. PP OP IPAcademic : R2R, KM, NHESMoPH.NHSO. NHCO.Thaihealth. etc.Policy directionStrategic PlanResource supportSocial mobilizeAdvocacyM&ELGs./Health care delivery/PHO./RegionalHealth care service deliveryQuality improvement of careData registrySelf asses. & monitoringAppropriate innovative tech.R2RAcademic organization/ UniversityEvidence-based guidelineStandard & QualityCapacity buildingDevelopment ResearchInnovative interventionHealth care service delivery(P&P, Care, Rehabilitation)Community ,Primary , Secondary , Tertiary

Health outcome , Quality of Life, Financial outcome, Evidence & Knowledge based Management, Governance managementSharing/UtilityTransfer/Feedback Improvement DevelopmentCardiac centerAdministrative framework for DM/HT1st prevention2nd preventionCKDPrevention Gr. 1 - 31.CAPD2.HD3.KTRRT CenterRetinopathy Rx. (LASER/op.)Stroke fast tractStroke Awareness StrokeAlertACS AlertPlanDM/HTHealth exam and screening CVD1.HbA1C2.LDL3.BP4.Micro albuminEye examFoot examPlanP&PPre- DMPre- HTScreeningBehavior ModificationImprove Quality of Rx.Prompt Rx.Early detect & registry3rd Prevention & CareLocal health fundsVerbal screeningReduced risk/behavior modification supportSelf help group support (DM & HT)CKDClinicSource: National Health Security Officecm20 , sm3Cm 11,sm 4cm13 ,sm4Cm27,sm31. Cm 47 ,sm42. C m 7 ,sm63. Cm 14 ,sm44. Cm 10 ,sm35. 6. 7. Cm 8,sm4 Cm3 ,sm7 Cm38. Cm 19,sm79. Cm 1010. C m 6,sm4cm14,sm4Cm 9 ,sm4Cm 6 ,sm4Cm 8 ,sm4Cm 19 ,sm3Cm 9,sm5Cm 8,sm4Cm12,sm4Cm 16,sm9Cm 15 ,sm3Cm 15 ,sm4Cm13,sm3Cm 17 ,sm4Cm 20,sm4Cm 10 ,sm4Cm 26 ,sm4Cm7,sm4Cm 26 ,sm4Cm 9 ,sm4Cm 9,sm3Cm 15 ,sm4Cm 6 ,sm3 Cm 10 ,sm5 Cm 13 ,sm4Cm 9 ,sm2Cm 9 ,sm3Cm 11Cm 6 ,sm4Cm 9 ,sm4Cm 7 ,sm4Cm 14,sm6 Cm 8,sm4Cm 12 ,sm4Cm 20 ,sm4Cm 9,sm4Cm 13,sm4 Cm 8,sm5Cm 14 ,sm 4Cm 11 ,sm4Cm 14,sm3Cm 11,sm4Cm 6Cm 14,sm8Cm 11Cm 8 ,sm6Cm 8 ,sm4Cm 17,sm 4Cm7,sm6Cm 8,sm4 Cm 7 ,sm4Cm 8,sm4Cm 11,sm4Cm13,sm4 Cm 13Cm 14,sm4Cm 15Cm 5,sm4Cm4Cm 22 ,sm6Cm 12 ,sm4Cm15,sm4Cm 8,sm4Cm 15,sm5 Ca1p.acNituy rbsueildCinagsfeormcharonnaicgcearre1.Ca(sCe mMa)na1ge,0r (6C4M)1 ,0 64 p7e7rso n s (7 7 pr ovinces) 2.2.SySsytesmtemmanamgera(nSMa)g3e6m5 peernsotnste(7a7mprovinces)(SM) 365 77

2557 SM =Provincial Health office, District health office, Specialist Medical doctor, NurseCM=Nurse and health personnel in heath centerCapacity building of health personnelSource: National Health Security OfficeSEXMale femaleAge15 -34 year35 60 year61 -70 year> 70 yearBMI (Height and Weight) 23 27.5> 27.5Waist measurement male80cmBlood Pressure YesNoAlcohol drinking YesNo Smoking YesNo GeneticYesNoSCEENING RISKHealth Voluntary well trainFasting plasma glucoseNo risk groupRisk groupClinic DPAC : Diet and Physical Activity Clinic NCDClinicPopulation Based approachIndividCase ManagerHealth Center incommunityPublic Health PolicyHealthy Food, Physical activity, smoking and alcohol reduction risk strategyBuilding of healthy public policyCreating supportive environments Strengthening community action Developing personal skills Reorientation of the health serviceAbA1c >7%Local governmentLocal health fundsMini Case ManagerSYSTEM MANAGERPatient without complicationual Based approachPatient withcomplicationAbA1c in diabetic patient during pass 4 years (2011 -2014)26.314.88.96.727.017.118.339.143.732.732.77.07.417.820.0212.31.620.919.621.329.332.245.337.666.777.873.373.357.052.163.260.331.624.122.029.70.010.020.030.040.050.060.070.080.090.0100.02011201220132014201120142011201220132014< 35 year2012201335 -60 year>60 yearUnder control HbA1C8%Source : Huaiyot District N= 3,196 cases13.86.615.86.116.914.66.614.720 18.9181614121086420DrinkingDrinking and smokingPercentageSmoking Substance use200120072014Drinking and Smoking Behavior among age> 15 yearSource : Health National survey, National statistic organizationSocial Protection Intervention : Smoking bans and restrictions, Increasing the unit price for tobacco products, friendly clinic , Prevention second smoker etc.16.213.918.219.720.413.011.023.121.620.616.43.17.29.43.74.17.38.46.17.29.22.14.215.216.314.915.214.917.317.51921.512.416.513.515.105101520251234589101112Percentage67Province of studyDrinkingSmokingDrinking and Smoking> 15 yearDrinking and Smoking Behavior among ageby province in 2014N= 450 cases in each province, National statistic organizationNumber and % of quitsmoking21546134152851912151592351513162142.93534.329.644.160.031.133.33148.446.431.44843.80102016163026.24050607080 741234589101112Number67DPAC and NCD ClinicSmoking Cessation Clinicquit%102136971521976919410071188138125545452789559454979735852.939.753.651.348.24655.245.069.042.052.946.430.4

050100150200250123489101112Alciholquit%Number and % of Stopdrinking567

DPAC and NCD ClinicSubstance dependence is a common and costly chronic illness associated with medical and psychiatric comorbidity.Treatment can be efficacious when it is actually received by patients. But the current system of care is fragmented, not coordinated, and does not always include proven efficacious treatments.Patient motivation and coexisting health and social problems are barriers to receipt of effective treatment.Integrated and coordinated care, which simultaneously addresses patient motivation and needs across health domains, provides efficacious addiction treatments and facilitates effective access to other treatment.This integrated care may increase the likelihood that care is received and that addiction-related and other clinical outcomes improve.Substance dependence : Chronic ConditionChronic Care Model (CCM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability.

The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care.

The CCM model goes beyond integrated case management by a professional, collocation of services, and integrated medical and addiction careelements that individually can improve outcomes. Supporting evidence is presented that: 1) substance abuse is a chronic disease requiring longitudinal care, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CCM has been proven effective.ConclusionAddiction Therapy 2016 Website: addictiontherapy.conferenceseries.comMeet the eminent gathering once again atAddiction Therapy 2016Miami, USAOctober 06-08, 2016