The Chronic Care Model as a vehicle for the development of disease management in Europe Professor Cor Spreeuwenberg MD PhD Department Social Medicine Faculty of Health, Medicine & Life Sciences Maastricht University INIC-Conference Gothenburg, 6th March
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The Chronic Care Model as a vehicle for the development of disease management in Europe Professor Cor Spreeuwenberg MD PhD Department Social Medicine Faculty.
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The Chronic Care Model as a vehicle for the development of disease
management in Europe
Professor Cor Spreeuwenberg MD PhDDepartment Social Medicine
Faculty of Health, Medicine & Life SciencesMaastricht University
INIC-Conference Gothenburg, 6th March 2008
Content
Chronic Diseases Some care approaches The Chronic Care Model US and Europe Conclusions
Chronic diseases: world wide
Chronic Diseases
disaster or blessing?
Aims of chronic care
prevention or delay of manifestation(s), where possible
improved functioning of patients - reducing symptoms and complications - prolonging lifespan - improving quality of life - living independently - according own needs, demands and
preferences effective, efficient and safe health care delivery
Challenges of chronic care
access prevention & lifestyle integrated care effective and efficient care (delivery) co-morbidity and multi-morbidity tailoring to the needs of patients support of self-management organization on different levels care management support manpower
0% 10% 20% 30% 40% 50% 60% 70%
BMI 27,0+
BD 150+/85+
TotChol 5,0+
Hb1Ac 7,0+
Geen funduscontrole
Geen voetcontrole
Rokers
Uitkomstmaten van alle patiënten met volledige 24-M dataset; n=15.260 (van 48.441)
0% 10% 20% 30% 40% 50% 60% 70%
BMI 27,0+
BD 150+/85+
TotChol 5,0+
Hb1Ac 7,0+
Geen funduscontrole
Geen voetcontrole
Rokers
UItkomstmaten van alle patiënten met volledige 24-M dataset; n=15.260 (van 48.441)
T24T12T0
0% 10% 20% 30% 40% 50% 60% 70%
BMI 27,0+
BD 150+/85+
TotChol 5,0+
Hb1Ac 7,0+
Geen funduscontrole
Geen voetcontrole
Rokers
Uitkomstmaten van alle patiënten met volledige 24-M dataset; n=15.260 (van 48.441)
Do we treat all aspects effectively?Results of systematic approach of people with diabetes (N= 15.269) at T0, T12, T24
Lessons
Supporting practitioners to improve their medical skills seems to be more effective than paying attention to behavioural interventions
However
1. There are al lot of indications that most practitioners are not skilled in applying behavioural interventions
2. Behavioural interventions require different approaches, time-sets and ways of patient involvement
Approaches to improve chronic care
quality: integrated care efficiency: disease management outcomes: Chronic Care Model
Question: do these approaches exclude each other?
Integrated care- definition WHO (Gröne, Garcia-Barbero), 2001- presented on IJIC-conference in Strassbourg, 2002
Integrated care is the bringing together of - inputs, delivery, management and
organization of services - related to diagnosis, treatment, care,
rehabilitation and health promotion.
Integration is a means to improve services in relation to access, user satisfaction and efficiency
Integrated care(Kodner/Spreeuwenberg, 2002)
pragmatic definition: a step in the process of health systems and health care delivery becoming more complete and comprehensive
contains a coherent set of methods and models on funding, administrative, organizational, service delivery and clinical levels
designed to create connectivity, alignment and collaboration within and between the cure/ care sectors
aims to enhance quality of life, consumer satisfaction and system efficiency for patients with complex, long-term problems cutting across multiple services, providers and settings
Disease Management- definition according to DMAA (2004)
a system (of) coordinated health care interventions and communications
(for) populations with conditions (in which) patient self-care efforts (are) significant
Disease managementbackground
originally an American concept one disease or health problem feedback mechanism based on management
information focus on efficiency more than on quality population orientation programmatic, systematic approach usually organized by a third party
2007: DMAA changed its name to
Care Continuum Alliance
care continuum includes strategies such as - health and wellness promotion - disease management and - care coordination Care Continuum Alliance promotes the role of
population health improvement in - raising the quality of care - improving health outcomes and - reducing preventable health care costs for people with - or at risk for developing – chronic conditions
The Chronic Care Model
Chronic Care Model: Aim
To improve functional and clinical outcomes
by relating processes on different levels- - patient- - practice team- - organization responsible for the practice
team- - health care system- - society
Chronic Care Model: central issue
Creating a productive set of interactions between patient and practice team
“Informed, activated patient”Application of principles of citizenship:patient as ´owner’ of the disease
understands principles of treatment able to make informed choices able to cope with relevant technology knows signs/symptoms of complications knows who to call for support active in preparing the next consultation
This is an intention, but keep in mind that not all patient are capable to act on this way!
Self-management
Support of Self-management - information and education of patients -
‘’Prepared and pro-active practice team’’
Competence in clinical care, attitude,organization and communication
up-to-date knowledge and skills multi-disciplinary team accessible and transparent ready to support and to inform front- and back office co-operation issues delegation of tasks, if justifiable application modern technology
A Network Information and Collaboration System
Patient
Personal Health Management
PersonalHealth Record
Selfmanagement Patient
education
Protocols
Processes Documentation
Forms
Populationmanagement
Outcomemanagement
Decision support
Screening
Monitoring
Benchmarkrapports
General Practitioner Researcher
Practice nurse Medical specialist
PsychologistDietician
Physiotherapist PodotherapistGeriatrist
Chronic Care Model: related components or
conditions
Community-level: . resources and policies
Health care delivery system-level . health care organization . delivery system design
Practitioners/team-level . clinical information systems . decision support . self-management support
Evidence based strategies with high success factors
Support of self-management - preventive messages (web etc.) - self care education Practice-level: - disease registries to identify and track people - risk stratification models - services in community settings Substitution from physicians to nurses
Europe: its health systems and chronic care approaches
EU or related position health care national issue nationalized and mixed public/private systems various ways of organization various approaches to market
mechanisms various ways of chronic care management cf Ellen Nolte
Europe: disease management and Chronic Care Model: general
picture
much support for CCM disease management initiatives
independent from nature health care system
disease management approaches compatible with CCM-model
discussions within governments about their role in implementing disease management
success also dependent of role of professionals
Converging of American and European chronic care
approaches
stratification based on complexity and patient features
continuum of care connectivity of personal, practice and system levels prevention - and lifestyle influencing support of self-management availability and interconnectiveness of information quality control and improvement mechanisms improved functioning of the health care team information technology
Vast majority of pts: Non-complicated pts. - Supported self-care - practice nurses/GPs
2
1
3
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From challenges to changes
Implications:
- organisational - status and tasks of professionals - educational - financial
Implications of change are significant, but
the implications of not changing are even more significant
Chronic Care Model (its principles) as a vehicle for disease management approach
DM-approach:- provoked by new health legislation (2006)- intended for all chronic diseases with
important prevalence, starting with diabetes- new entities, often regional embedded, which
function as organizer and contractor- most entities formed by GPs- insurers supposed to set the rules- entities subcontract concrete caregivers- data gathering bij a national institute (RIVM)- starting problems (ICT)- at this moment weak attention for CCM-
aspects
Opportunities to integrate disease management approach with CCM
- development of care standards (how to use guidelines in daily practice)- subjects: . diabetes, COPD, cardiovascular risk management . to be developed: heart failure, depression etc. . newly written care standards take CCM as
starting point- Conclusion: CCM can function as a vehicle to introduce a adapted way of disease management
Main messages
The CCM can be successfully combined with a diseases management approach
Care patterns must be based on complexity of health problems and readiness of patients for self-management
The nature of chronic diseases, together with the upcoming shortage of staff, require a combined effort of all involved to develop powerful systems of self-management
Care standards based on CCM may function as a vehicle to start with a European variant of disease management
DM-organizations that mainly serve the interest of regional practitioners, may hinder the effectiveness and quality of chronic care in that region