Integrated Service Delivery and the Role of Hospitals in

Chronic Disease Management:Analytical Perspectives

and the Canberra Case Study

Associate Professor Paul DugdaleEuropean Forum for Primary Care Conference

Galatasary University, Istanbul September 2013International Hospital Federation Workshop

Improving the response of hospitals to patients with multi-morbid chronic conditions

• Background and Policy Context• An approach to understanding reform:

Organization; Expertise; Financing.

Chronic Disease Management in Canberra Hospital and Health Services

• Current services• Efforts to integrate with primary health care

Fishing near Canberra

Improving the response of hospitals to patients with multi-morbid chronic conditions

• The Increasing Burden of Non Communicable Diseases

• Combined with current problems in service provision:– Lack of integration between primary and referral based

care– Lack of access to primary care drives over-provision of

hospital and referral based care• Gives clear potential for health gain.

Burden of Chronic Disease• Most of the world’s population is living longer and dying at

lower rates. • Leading causes of death are shifting to non-communicable

diseases. • Worldwide, the number of people dying from non-

communicable diseases grew 30% in the 20 years to 2010. • Preventive health care has resulted in more people with chronic

disease (!)• People are living to an older age, but partly because of this they

are experiencing more ill health, reflected in disability increases • in middle- and high-income countries this is due to diabetes,

musculoskeletal disease, depression, CVD and stroke. • In poor countries, the burden of disease is shifting too, with the

burden from hypertension, diabetes has markedly increased.

Current problems in health service provision

• Without universal coverage, people with multiple chronic diseases are often the least able to afford health cover.

• They may have some access to primary health care, but little access to referral based specialists or inpatient care,

• Or access to inpatient care only in life threatening emergencies.• With comprehensive access to health services, they may be

subject to turf battles over whether GPs or specialists ‘own’ the patient.

• Inter-specialist referrals may fragment care, lead to unnecessary investigations, and reduce the role of primary care physicians.

• In conflicts between busy inpatient units with each trying to ‘disown’ the patient in emergency that clearly requires admission.

Current problems in health service provision

• hospital-centrism reduces access to primary health care • In over-commercialized health systems, people with multi

morbidity are particularly prone to supplier induced demand.• coordination between hospitals, primary medical care and

community services is difficult and inadequate.• multi morbidity requires support from non-health sectors.• participation in civil society is challenging, they may be

effectively disenfranchised. • Their reliance on carers puts strain on themselves and their

carer, and there is potential for abuse. • Support for carers is often lacking in health systems, even in

high-income countries.

Potential for health gain• Given the increasing burden of non-communicable

disease and the sub-optimum state of health care systems, there is widespread potential for health gain

• through improving the way hospitals link with primary and community based care.

• This will require a shift on both sides from episodic care toward coordinated, tracked or managed care.

• Hospitals and their associated health care services will need to maximize their contribution to population health gain for patients, not just curate their acute support during inpatient episodes.

Doing comparative research in Canada

UN and WHO Policy Context

• Political Declaration on the Prevention and Control of Non-Communicable Diseases (UN 2011 A/RES/66/2).

• WHO promoting a ‘patient-centred model to coordinate management of chronic diseases from prevention to palliative care, at all levels of the health system, across institutional boundaries (primary health care, social care in the community, hospital services, emergency care)’ (WHO Europe 2012)

Pan American Health Organization

• Promote integrated health service delivery networks for the organization of the response to NCDs.

• They recognize the increasing intensity of service delivery needed as NCDs progress and patients acquire multiple diseases; and

• emphasise the importance of horizontal integration between hospitals, primary health care and community services including social services through a people centred approach. (PAHO 2011).

Analysing Health System ReformAssemblage of the health system

Organisation

Expertise Financing

An approach to reform

• Knowledge developments: from disease specific to multi-morbidity studies

• Organisational developments: from service centred to people centred care

• Financing developments: from incentivizing throughput to continuity of care

Health system reform directionTraditional assemblage Emerging assemblage

Service centred management Patient centred services

Disease specific Episode incentives Understanding Continuity incentives

Knowledge of multi-morbidity

Reform Direction

Organizational Reforms

• Drive toward people centred models of care supported at all governance levels and recognised in accountability frameworks.

• Leading hospitals have expanded to offer a broader range of services, including non-inpatient referral based specialist services in medicine and allied health, satellite clinics, and community outreach services.

• Toward integrated management of regional hospital, primary care and community service networks.

Organizational Reforms

• The expanded footprint gives great scope to support primary health care services, and support health promotion efforts.

• need to reorient logistical efforts to make care efficient and coordinated from the patient’s point of view.

• Clinical information systems which operate across settings provide formidable capability.

Now: Data illuminates Research and Management

Soon: Data illuminating all of health care

Reforming the Evidence Base

• Elucidation of common risk factors for multiple diseases eg diabetes, atherosclerosis, renal disease, depression

• Global Burden of Disease work (Murray Gates)• Guidelines for the management of common

combinations of diseases involving multiple organs and specialties.

• New strong measures of global well-being

Reforming the Evidence Base

• Research on Wagner Chronic Care Model• Research on the Burden of Healthcare • Research into soft technologies – better ways of

doing things, of cooperating, new systems of care, improvements in communication.

• Is always conducted in-vivo.• Requires dialogue and negotiation with those

being researched (patients as much as medical specialists).

Reforming Health Financing

• 50 years since the publication of Arrow’s analysis of health insurance in 1963

• WHO has swung from disease programs (1950s-60s) to Primary Care and Health for All (1970s-80s) to targeted programs (MDGs) to Universal Health Coverage.

• UHC orients financing for care of multi-morbidity toward continuity of care.

• But payment mechanisms to promote this are unclear.• Financing programs often cause primary and referral

based care to dis-integrate.

Current Questions

• How can we accelerate integration between primary and referral based care?

• What structural change will drive this? Regional comprehensive care organisations? PCOs? Private sector incentives/contracts?

• How should movement toward UHC be linked to planned improvement in services?

• And what role does reform of governance in the health system play in this linkage?

Chronic Disease Management in Canberra Hospital and Health Services

• CDM Register• Disease Audits• CDM clinics and services• Care Audits• Future directions

Background

• Epidemiological and demographic transition • Rising tide of chronic disease• Diabetes, COPD and CHF account for the

majority of the ameliorable burden of chronic disease

• Government made the resource allocation• Someone had to pull it together on the shop

floor of the health service jungle

Skating on Canberra’s thin ice

The CHHS CDM RegisterOn the MacColl Assessment of Chronic Illness Care Survey, our Clinical Information System pulled the whole level of support

for the Chronic Care Model down to only the ‘Basic’ level.

CHHS CDM Register

• One of Canberra Hospital and Health Services’ clinical information systems.

• Patients discharged from the Canberra Hospital with Diabetes, Chronic Obstructive Pulmonary Disease or Chronic Heart Failure

• or received care from some of the services that participate in the Chronic Disease Management Clinical Network Includes case management information for a range of clinical services.

CHHS CDM Register

• Hospitals ,like GPs, should know their CD patients • and track the care provided to them.• The CDM Register draws on CHHS data records– demographics, – diagnosis, – therapeutics and – Support for self management

• Highly compliant with eHealth and HL7 standards

Diabetes Management Audit

• 1029 CDMR patients with a HbA1c test performed since 1 January 2010,

• 73% had their HbA1c checked in the previous 6 months.

• 40% of patients had a HbA1c less than or equal to 7%

• Detailed, identified results provided to 12 service units, updated monthly

Kidney Disease Audit

• 2386 CDMR patients with an eGFR result since Jan 2010

• 69% had a result recorded for the previous 6 months

• 30% have at moderate or severe loss of kidney function (eGFR<60)

• Detailed, identified results provided to 12 service units, updated monthly

Nursing Team of the Year 2012

CDM Services

• Management consulting– Implementing the chronic care model– QI, Evaluation, student and registrar research projects– Budget submissions (eg Obesity Management Service)– We convene and support a CDM Clinical Network

• Home telemonitoring– Telemedcare monitors– Sick patients with multiple chronic diseases– Physiological stabilisation– Confidence for CD Self Management

Nurse-led clinics and services

• COPD CNC Service for frequent users of the acute care sector with COPD– education, – clinical support and – care coordination.– Smoking cessation clinic

• Close links to Pulmonary Rehabilitation Program• Reciprocal support arrangements with

Respiratory physicians

Nurse-led clinics and services

• Parkinson’s Disease and other Movement Disorders CNC Service

• Clinics at Canberra Hospital and University of Canberra private clinic

• Apomorphine service with commencement in Hospital In The Home

• Close working relationship with Neurologists• Strong support from the ACT Parkinson’s

Disease Society

Nurse-led clinics and services

• Heart Failure CNC Clinic– In parallel with Cardiologist Outpatients– Phone and home visit followup available

• Heart Failure Rehabilitation Course– Grew out of Cardiac rehabilitation course– 12 weeks of exercise and education

• Heart Failure Inpatient Consult Service– CDM supports cardiologists to provide this, and

use it as a feeder for the CNC clinic and HF course

Our friendly staff will sign you on for trials, eHealth and special offers

Advance Care Planning Clinic

• All staff participate• Preparatory discussions in the course of care• then clinic booking made for decisions and

signing• Two staff, patient and carer all need to be

present for legal reasons.

Care Coordination Service

• For COPD, Parkinson’s and CHF• Referrals assessed by CNCs• Care coordinators develop Flinders Care Plans

with patients• Focus on patient goals linked to self

management strategies, education and coordination of community and other support services

• Linkage to general practice is patchy

CD Telephone Coaching Service

• Telephone based service to improve self management for people with – Chronic Heart Failure, – Coronary Artery Disease, – Chronic Obstructive Pulmonary Disease– Diabetes. The service is being delivered by an

• We have teamed with Medibank Health Solutions• Referrals or CDM Register-based patient selection• Single consent process

CDM Performance Monitoring

• Detailed performance monitoring for all services

• Regular, one-off and research grade comparative audits for each service using the CDM Register

• Occasions of Service tracking from the Patient Administration System

• HbA1c and eGFR from ACT Pathology

Audit of Care Plans for 2209 patients on the CDM Register

Number of participants with any care plan and with a CDM care plan

Numbern-2209

CDMR alln (%)

CDMR othern (%)

CCP n (%)

Cardiac rehabn (%)

TTCPn (%)

Total Registered(31/03/11)

2202 (100%) 1337 (61%) 325 (15%) 416 (19%) 124 (6%)

No. with any care plan 1423 (65%) 839 (63%) 234 (72%) 236 (57%) 114 (92%)

No. with CDM care plan 464 (21%) 216 (16%) 105 (32%) 45 (11%) 98 (79%)

Type of in-scope care plan

Total Care plans in all patients: % of total care plans per group

0 10 20 30 40 50 60 70 80

Acute Rehabilitation / RILU Care Plan (65365)

Care Co-ordination and Service Plan (65235)

Care Plan (65000)

Chronic Care Program Care Plan (65230)

Conference / Family Meeting (65295)

Discharge Referral- Veteran's Liason (65005)

Falls Care Plan (65100)

Goal Planning Sheet / ACRS / RILU Care Plan (65366)

Inter-Disciplinary Care Plan (65010)

% of total care plans in group

TTCP

CDM

CCP

Cardiac Rehab

Future directions

• We are working with the local Primary Care Organisation

• On integrating our Chronic Disease Management Team with their Practice Support Team

• Deepening our involvement with general practice to include practice managers and nurses

• Overcoming distrust on both sides

Summary

• Hospital Networks should know their patients with chronic disease, track and coordinate their care appropriately.

• Aggregate chronic disease management services to achieve critical mass, visibility and flexibility

• Work closely with general practitioners• Build in QI, research and performance

management

Thankyou !

• Go to www.act.gov.au and search for ‘Chronic Disease Management’