CHRONIC DISEASE MANAGEMENT Case Study Calgary/Canada, 2002-2009

Belo Horizonte November 11 -12, 2014

Where is Calgary ?

Rocky Mountains

Winter City

Hockey

Chronic Illness

• “ Surveys across a variety of diseases including high blood pressure, diabetes, coronary artery disease, asthma and congestive heart failure have shown that 40 to 80 percent of patients are inadequately treated.”

Deficiencies include

• Rushed providers not following established practice guidelines

• Lack of care coordination • Lack of active follow-up to ensure the best

outcomes • Patients inadequately trained to manage their

illnesses

The System Needs to Change

• Our health system is designed to manage acute illnesses, not manage (much less prevent) chronic ones

• …and each system is perfectly designed to get the results it achieves

W. Edwards Deming, US Management Consultant, 1900-1993

World Health Organization

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Chronic Care in Calgary

To better address the problem of chronic disease, Calgary:

Formally began a Chronic Disease Program in 2002

Appointed a 1.0 Director and .5 Medical Lead

Targeted diabetes and hypertension

Provided project dollars

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Chronic disease management can’t be an add-on to someone’s current job

Key to Success

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Underlying Principles

Focus on secondary prevention

Use a ‘proven’ model of Chronic Care

Focus on building infrastructure rather than management of individual diseases

Be patient-centered and community-based

Work within existing operations

Be flexible with implementation

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Key to Success

At developmental stage need people who can think outside the box

Guiding Framework – Chronic Care Model

• Developed in mid 1990s at MacColl Center for Health Care Innovation (Seattle)

Has been applied to a variety of chronic illnesses, health care settings and target populations

Shown to improve patient outcomes and reduce costs for many chronic conditions

www.improvingchroniccare.org

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Chronic Care Model

Productive Interactions

Prepared, Proactive

Practice Team

Improved Outcomes

Delivery System Design

Decision Support

Clinical Information

System

Self- Management

Support Resources &

Policies

COMMUNITY Health Care Organizations

Informed, Empowered

Patient

HEALTH SYSTEM

Health System

Create a culture, organization and mechanisms that promote safe, high quality chronic care – All levels of the organization need to visibly

support efforts to improve chronic illness care, – Develop agreements that facilitate care

coordination within and across organizations

Delivery System Design

Assure the delivery of effective, efficient clinical care and self-management support – Define roles and distribute tasks among team – Use planned interactions to support care – Provide case management for complex patients – Ensure regular follow-up by the care team – Give care that patients understand and fits with

their cultural background

Decision Support

Promote clinical care that is consistent with scientific evidence – Embed evidence-based guidelines into daily

clinical practice – Use proven provider education methods – Integrate specialist expertise and primary care

Clinical Information Systems

Organize patient data to facilitate efficient and effective care – Provide timely reminders for providers and

patients – Identify relevant subpopulations for proactive care – Facilitate individual care planning – Share information among providers to coordinate

care

Self-Management Support

Empower patients to manage their health and health care – Emphasize the patient’s central role in managing

their health – Use effective self-management support strategies

that include goal-setting, action planning and problem-solving

The Community

Mobilize community resources to meet needs of patients – Encourage patients to participate in effective

community programs – Form partnerships with community organizations

to support and develop interventions that fill gaps in needed services

Key System Challenges facing Calgary

Variation in care

Lack of care coordination and follow up

Limited use of multidisciplinary team

Patients inadequately trained to manage own illnesses

Financial incentives did not support good chronic illness care

Developed Care Algorithms

–Specified the care that was to be provided, by which provider, when and where

Developed for the key chronic conditions

All providers were involved

Led by medical specialists

Identified gaps in provider education

Assigned Multidisciplinary Teams to Support Family Physicians

–Some team members co-located in doctor’s offices to follow up patients (eg nurses)

–Others work in community settings to deliver patient education and provide supervised exercise programs (eg kinesiologists, physiotherapists, dietitians)

–Medical specialists provide in-services and support for complex patients

Living Well Community Program

• Living Well program provides:

Supervised exercise classes

Disease-specific education

Self-management classes

Aim of Program

Be accessible. Offered in community settings, e.g., gyms and community centres

Provide ‘one stop shopping’ for participants

Be sustainable – link with community organizations to expand reach

Be appropriate for people with a range of chronic conditions

Living Well Program

• Agreements with other organizations to provide disease education classes at sites

• Patients feel safe exercising as health professionals run class

• Program provide social support to patients

Introduced Self-Management Training for Patients

–Adopted the Stanford Chronic Disease Self-Management Program

Developed by Dr Kate Lorig in the 1980s at Stanford University (patienteducation.stanford.edu)

6 week program suitable for anyone with a chronic condition

Taught in small groups, by lay people

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Characteristics of Program

• Standardized training for leaders • Highly structured teaching protocol • Standardized participant materials • Sesame Street approach

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Core Assumptions

•Patients with different chronic diseases have similar self-management problems and disease-related tasks

•Patients can learn to take responsibility for the day-to-day management of their disease(s)

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Core Assumptions

• Trained lay persons with chronic conditions can effectively deliver a structured patient management/ education program

• Patient self-management education

should be inexpensive and widely available

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Patients spend less than .1% of their time in the physician’s office

Time spent in doctor's office (0.07%) vs. Time in self-management (99.93%)

(based on total of six hours per year)

Self-ManagementDoctor Visits

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35

36

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Introduced Care Plans

•A way for providers and patients to work together to manage a patient’s chronic conditions • Care plans outline the patient’s goals, upcoming interventions

and the role of all the providers involved in the care

•Why is care planning important? • Takes focus away from disease to patient as a whole • Facilitates communication between patient and providers • Is motivational for patients • Integrates medical and self-management

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Evidence for Care Plans •Better clinical outcomes

•Improved quality of life

•Reduced hospital admissions, unplanned GP visits, emergency visits

•Increased satisfaction with service

•More efficient clinical practice http://som.flinders.edu.au/FUSA/CCTU/contact.htm

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New Fee Code in Alberta for Family Physicians • 03.04J Complex Care Plan – the development,

documentation and administration of a comprehensive annual care plan for a patient with complex needs…$206.70 (Launched April 1, 2009)

•Patients must have at a minimum, either: • 2 from A; or • 1 from A and 1 from B

Column A •Hypertensive Disease (ICD-401) •Diabetes Mellitus (ICD-250) •COPD (ICD-496) •Asthma (ICD-493) •Heart Failure (ICD-428) •Ischaemic Heart Disease (ICD-413-414)

Column B •Mental Health Issues (ICD-290-319) •Obesity (ICD-278) •Addictions (ICD-303-304) •Tobacco (ICD-305.1)

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New Fee Code Launched April 1, 2009

Source: Calgary Herald, March 16, 2009

Monitor progress

Results

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Results – ACIC (Assessment of Chronic Illness Care)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

Mea

n Ra

ting

(0-1

1)

Literature (N=90) 2003 (N=27) 2007 (N=41)

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Results – HbA1c Control

0%

10%

20%

30%

40%

50%

60%

70%

80%

% <

= 7

%

Baseline 12 – Months

All (N=5492) Population

17% more patients with diabetes had blood sugar under control, p < .001

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Results – Hypertension

10% reduction in blood pressure among those at higher risk, p < .001

100%

110%

120%

130%

140%

150%

160%

180%

Mea

n Sy

stol

ic B

P

Baseline 6 – Months

All (N=464)

170%

High Risk (N=115)

134 131

160

145

High risk = > 145 at baseline

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200

400

600

800

1000

0

300

500

700

900

Visi

ts P

er 1

000

Patie

nts

Baseline 12 – Months

All (N=17233) Population

Results – ED Visits ED visits dropped by 34%, p < .001

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Inpatient Admissions dropped by 41%, p < .001

50

150

250

350

450

0

100

200

300

400

500

Visi

ts P

er 1

000

Patie

nts

Baseline 12 – Months

All (N=17233) Population

Results – Inpatient Admissions

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Bed days dropped by 31%, p < .001

Visi

ts P

er 1

000

Patie

nts

Baseline 12 – Months

All (N=17233) Population

0

1000

2000

3000

4000

6000

5000

Results – Bed Days

Key to Success

• Paradigm shifts take time

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Stay below the radar while testing different approaches and ideas

Key to Success

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At the Closing Bell…

‘ Progress is impossible without change and those who cannot change their minds cannot change anything ‘

George Bernard Shaw