1

Dealing with Complexity:The Bridgepoint Health Hospital Experience

Renee Lyons, Ph.D.Chair in Complex Chronic Disease Research andScientific Director, Bridgepoint Collaboratory for Research and InnovationProfessor - Dalla Lana School of Public Health, University of TorontoDale Min, Kerry Kuluski and Alexis Schaink

Quality of Care for People with Multiple Chronic Diseases: New Opportunities and Challenges ForumGranada, SpainTuesday, June 1, 2010

2

Overview

• Third Frontier (Multi-morbidity, Complex Chronic Disease, and the Deficit Crisis)

• Bridgepoint Health and the Collaboratory

• Research initiatives

• Opportunities for Collaboration

3

The Third Frontier: Complex Chronic DiseaseWhat is it?• More than one chronic disease• Complex care (individualized, patient-focused but systematic)• Coordinated, linked up care over time• Data and metrics that reflect complexity• High prevalence of mental health problems• High prevalence of social, economic, and/or cultural issues• High risk for additional health problems and hospitalization• Self management and family support are challenges• Patient flow an issue• Health system re-design needed!

4

CCD Intersects with Many Factors

Mental Health

Environment

Quality of Life

Socioeconomic Status

Family

Culture

5

In Contrast to the Health System Focus• Acute care – designed for short-term episodic care• Reactive models• Treat and street• Ineffective for prevention and treatment• Patient and family experience usually unsatisfactory• Inadequate attention to prevention (tipping points)

6

Global Burden of Chronic Disease

• The main cause of death and disability worldwide – 60% of all deaths (Abegunde et al., 2007)

• In 2030, predicted to cause 75% of deaths worldwide (WHO, 2008)

• In the UK, 80% of GP consultations CD; 80% of people living with long-term conditions needed support for self care (DH, 2004)

7

Health Care Expenditures in Canada

• $39 billion or 42% of health care expenditures related to chronic disease (Mirolla, 2004)

• Total economic burden of 7 most prevalent chronic diseases (medical plus productivity losses) exceeded $93 billion (CDAC, 2004)

• 60% of the health care budget spent on chronic disease in Nova Scotia (Colman, 2002)

• Cost of CD varies by region by diagnosis (Manitoba Centre for Health Policy, 2010)

8

Complex Chronic Disease

• Heaviest users (Reid, 2003)

• 36% of diabetes health care expenditures associated with co-morbidity (Simpson et al., 2003)

• In Manitoba, 30.5% of all people with chronic disease have co-morbidities – 2 to 3 times as costly depending on the combination (MCHP, 2010)

• Co-morbidity management – acute model does not work. Increased symptom burden at high risk for developing additional health problems (Williams et al., 2007)

9

• Low-income Canadians are:– 50% more likely to report having a

chronic disease– 3 times more likely to report having 2

or more chronic conditions.(2007 Report on Ontario’s Health System; Ontario Health Quality Council, 2007)

Disparity/Economic Costs

10

11

12

Statistical Challenges in CCD

• Massive variability in prevalence, impact and distribution across populations/geography.

• Substantive variability in the unit of analysis and measures.

• Lack of common definition of CCD and valid index to measure complexity and capture burden

• Co-morbidity does not explain critical elements of prevention or management.

• Cost and use predictions not dependable.

13

Taking ActionPrevention/Population Health:

• Fifty percent of premature deaths and 70% of chronic disease in US is preventable. Up to 80% of premature deaths from CVD, stroke and diabetes could be averted by intervention (WHO, 2005)

• Attention to the social determinants

Care:

Patients in acute hospital medical wards are mostly older and have multiple co-morbid conditions that require complex and holistic care that the systems of case mix, diagnosis related groups and management systems do little to promote. (Williams, 2010, p.65)

14

Bridgepoint Health

15Toronto, Ontario, Canada

16

17

18

19

The Strategy Process

1995-2000

2004

2001 - 2004

Survival

An integrated network of services

New vision and

mission

2004 to 2006Canada’s

Leader Strategy

2006Six Year Business

Plan

Implementation!

We are here!

20

Four Key Outcomes of Strategy

• Reduce the burden of complex chronic disease

• Improve the quality of life and improve wellness for individuals living with chronic disease

• Create, share and disseminate new knowledge

• Drive societal and health system change

21

22

Bridgepoint Hospital• Publicly funded

• In-patient care

• Ambulatory and day services – 20,000 visits

• 479 beds: 367 complex & 112 rehabilitation

• 1,200 employees

• 400 volunteers

• Ethnically diverse

• Health disparities

23

In-Patient: Complex Rehabilitation

• Moderate to severe acquired brain injury

• Major surgery with complications

• Stroke with moderate functional impairment

• Elderly patients with hip fractures

• Multiple severe fractures/trauma

• Elective surgery, hip and knee replacement

24

In-Patient: Complex CareMultiple chronic conditions

• Stroke with major functional impairment

• Advanced progressive neuro-muscular disease

• Moderate or severe acquired brain injury

• Cardiovascular and respiratory complications

• Severe wounds

• Post-surgical complications

• Advanced diabetes

• Advanced HIV/AIDS

• End stage disease

25

Ambulatory Care: Day Treatment• Physiotherapy

• Occupational therapy

• Speech language pathology

• Social Work

• Nursing

• Vocational rehabilitation counseling

• Physiatry

• Spasticity Clinic

• Cognitive group

• Tai Chi group

• Acupuncture

• Pool therapy

• Pain management

• LEGSS (Lower Extremity Gait Support Services)

26

Bridgepoint: Family Health Team• Opened March 2008

• Primary care services:

• Nurse Practitioner

• Social Worker

• Dietitian

• Pharmacist

• Registered Nurses

• Physicians

• Research/Data Development

• LiveWell! program

27

The Bridgepoint Collaboratory for Research and Innovation in

Complex Chronic Disease

Leading edge research that advances understanding of and action on CCD prevention

and care

28Left to Right: Dale Min, Kerry Kuluski, Alexis Schaink and Renee Lyons

29

The Collaboratory

Researchers/AdvisorsAlex JadadCanada Research ChairGlobal eHealth

Ross Upshur Associate Scientist ICES and Sunnybrook

Chandrakant ShahProfessor Emeritus Dalla Lana School of Public Health

Harvey SkinnerDean of Faculty of Health York University

Louise-Lemieux CharlesChair, Department of Health PolicyUniversity of Toronto

Rick GlazierScientistICES and Li Ka Shing Knowledge Institute

Andreas LaupacisExecutive DirectorLi Ka Shing Knowledge Institute

Susan JaglalVice-Chair of ResearchRehabiliation research

Blake PolandAssociate Professor, Dalla Lana School of Public Health

30

Build from Strengths at Bridgepoint:

Dr. Bob Bernstein Data Development

Dr. Heather MacNeill COIL Project

Jane Merkley Skill Mix

31

Build from Strengths at Bridgepoint:

Kate Wilkinson Quality and Safety

Susan Himel LiveWell! Prevention

Project

32

5 Themes

5 Researchers/

Post-Docs

5 Research Teams

5 Grants

5

18 Month Objective

33

Emerging Themes

1) Data development and CCD

2) Quality and Safety Innovation

3) A CCD Training Platform – Collaborative Online Interprofessional Learning (C.O.I.L.)

4) Primary care

5) Facility design

34

Grants

1) International Post-Doctoral Cluster in Complex Chronic Disease

2) Partnerships for Health Systems Improvement

35

36

The Bridgepoint Study

• Define the Patient Population – The What?

• Patient and Family Need Assessments

• Asset Mapping

• Literature Review (of CCD populations and models)

37

The Bridgepoint Study

“How do we respond?” – The How?

• Determine the components of CCD models that are most relevant to Bridgepoint.

• “Think Tank” to develop a model based on evidence collected.

38

The Health Care Funding Crisis Opportunities for Collaboration:Efficiency and Effectiveness?

• Quality Patient and Family Experience

• Skill Mix

• Patient Flow

• Safety

• Prevention

• Blending Health – Social Development

• End of Life

• Mental Health

39

Opportunities for Collaboration

• Conceptual Development

• Data Development: Measures and Indicators

• Clinical and Health Services Intervention

• Population-based Health Systems Intervention

• Linked-up Services – Coordination

• Person-centered: Self Management Strategies

• Training/Decision Platforms

• Health Policy

40

Thank You!Contact InformationWebsites:http://www.bridgepointhealth.cahttp://www.lifechanges.ca

Email: RLyons@bridgepointhealth.ca