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DH Chronic Disease Management; the growing problem and strategic response 1.

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Presentation on theme: "DH Chronic Disease Management; the growing problem and strategic response 1."— Presentation transcript:

1 DH Chronic Disease Management; the growing problem and strategic response 1

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4 4 I don't always look after myself all the time … The truth is I am scared about the long term, I'm scared of going blind or having my legs chopped off. Self management is the cornerstone of diabetes care, however, you don't need to be an `expert patient' to take control of your own diabetes. You need a relationship with the right professionals to help you understand all the issues, make the right decisions, and achieve the right balance." What is it like having a chronic disease? Interview with Stuart Bootle, a GP who has had diabetes for 20 years

5 DH Chronic Disease Management; the growing problem and strategic response 5 The number of people with chronic conditions is rising (Source; General Household Survey 2002)

6 DH Chronic Disease Management; the growing problem and strategic response 6 And rising at all ages

7 DH Chronic Disease Management; the growing problem and strategic response 7 And it is likely to continue rising because

8 DH Chronic Disease Management; the growing problem and strategic response 8 The commonest chronic diseases are arthritis and rheumatism, and heart problems (including high blood pressure). (Source BHPS 2002)

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10 10 Women are slightly more prone to report chronic conditions; social class has a bigger impact though… ( source General Household Survey 2002)

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12 DH Chronic Disease Management; the growing problem and strategic response 12 Many people have more than one chronic condition

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14 DH Chronic Disease Management; the growing problem and strategic response 14 The predominant acute disease paradigm is an anachronism. It is shaped on a 19th century notion of illness as a disruption of the normal state produced by a foreign presence or external trauma,... Under this model acute care is that which directly addresses the threat. …. In fact, modern epidemiology shows that the prevalent health problems of today (defined both in terms of cost and health impact) revolve around chronic illness. Bob Kane

15 DH Chronic Disease Management; the growing problem and strategic response 15 There are important differences between acute and chronic conditions

16 DH Chronic Disease Management; the growing problem and strategic response 16 Poor CDM leads to wasteful use of high intensity resources. 80% of bed days in hospitals are currently used by emergency beds Of the eleven leading causes of bed use in the UK, eight are due to conditions that strengthened community care would lead to a fall in bed use

17 DH Chronic Disease Management; the growing problem and strategic response 17 50% of bed day use is accounted for by only 2.7% of all medical conditions, most of which are chronic diseases. (Source: HES data 2002) 50% of admissions are accounted for by 2.7% of all diseases 25% of admissions are accounted for by 0.67% of all diseases

18 DH Chronic Disease Management; the growing problem and strategic response 18 Having one or more chronic conditions increases your need for health care disproportionately

19 DH Chronic Disease Management; the growing problem and strategic response 19 And in some cases a few patients with chronic conditions end up on the revolving door 10% of patients account for 55% of bed use 5% of patients account for 42% of bed use

20 DH Chronic Disease Management; the growing problem and strategic response 20 What can we do?

21 DH Chronic Disease Management; the growing problem and strategic response 21 Self-care works visits to GPs can reduce by over 40% for high risk groups Fries J et al (1998) Reducing need and demand for medical services in high risk groups. West J Med 169: hospital admissions reduce by 50% in a Parkinsons disease Montgomery et al (1994) Patient education and health promotion can be effective in Parkinson's disease: a randomised control trial. The American Journal of Medicine Vol. 97: 429. outpatient visits reduce by 17% generally Lorig et al (1985) A work place health education programme that reduces outpatient visits. Medical care 23, No 9: hospital length of stay reduce for mental health problems Kennedy M (1990). Psychiatric Hospitalizations of Growers. Paper presented at the Second Biennial Conference on Community Research and Action, East Lansing, Michigan. medication intake more appropriate (e.g. steroids in asthma) Charlton et al (1990) Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice BMJ 301: A&E visits reduce significantly for patients with asthma Choy et al (1999) Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socio-economic status in Hong Kong. Clinical Experimental Allergy 29: days off work can reduce by as much as 50% for people with arthritis Fries J et al (1997) Patient education in arthritis: Randomised controlled trial of a mail delivered programme. Journal of Rheumatology 24, No 7:

22 DH Chronic Disease Management; the growing problem and strategic response 22 It gave me new ways of analysing and solving some of my problems... I believe that this is one of the most important initiatives for those with long-term chronic conditions The expert patient programme has really helped me to take more control of not just my arthritis, but also my life. Coming on the programme has given me real confidence to move on, plan for the future without fear, because I can now plan and pacereally good teaching. I have learnt that I need to take responsibility for my health instead of leaving it all to my GP. Quotes from the Expert Patient Programme

23 DH Chronic Disease Management; the growing problem and strategic response 23 Supporting chronic care To do this we need to consider the Three Rs; Registration of a population of patients for whom primary care teams identify problems, co-ordinate care and help support their condition. Recall of people to ensure they get the care they need by using prompts and reminders. Review patients to ensure they receive the best evidence based care and are supported to manage their condition

24 DH Chronic Disease Management; the growing problem and strategic response 24 Supporting chronic care For most patients this care will come from their general practice community nurses pharmacists other members of the wider PCHT

25 DH Chronic Disease Management; the growing problem and strategic response 25 Some patients with chronic conditions need more Some have a chronic condition that needs the occasional input of a specialist- often a community based (nurse) specialist- to avoid deteriorations and improve control: disease specific case management Others have a complex mix of social and medical problems, often leading to frequent re-admissions, unless they receive case management

26 DH Chronic Disease Management; the growing problem and strategic response 26 Disease specific case management There is good evidence about the impact of responsive community specialist services on specific conditions, for example heart failure Department of Health. National Service Framework for Coronary Heart Disease. HMSO, 2000.And Doughty RN, Wright SP, Pearl A, Walsh HJ, Muncaster S, Whalley GA et al. Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. Eur Heart J 2002;23: And Knox D,.Mischke L. Implementing a congestive heart failure disease management program to decrease length of stay and cost. J Cardiovasc Nurs 1999;14:55-74.And Stewart S, Blue L, Walker A, Morrison C, McMurray JJ. An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it? Eur Heart J 2002;23: COPD and asthma Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med 2003;163: And Morrison DS,.McLoone P. Changing patterns of hospital admission for asthma, Thorax 2001;56: And Baker D, Middleton E, Campbell S. The impact of chronic disease management in primary care on inequality in asthma severity. J Public Health Med 2002;25: And Naish J, Sturdy P, Griffiths C, Toon P. Appropriate prescribing in asthma. BMJ 1995;310:1472.And Barbanel D, Eldridge S, Griffiths C. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. Thorax 2003;58:851-4.And Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA) [In Process Citation]. BMJ 2004;328:144. diabetes Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001;CD And Sidorov J, Gabbay R, Harris R, Shull RD, Girolami S, Tomcavage J et al. Disease management for diabetes mellitus: impact on hemoglobin A1c. Am J Manag Care 2000;6: And Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R. Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria. Diabetes Care 2002;25:684-9.And Vrijhoef HJ, Spreeuwenberg C, Eijkelberg IM, Wolffenbuttel BH, van Merode GG. Adoption of disease management model for diabetes in region of Maastricht. BMJ 2001;323: and depression Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J et al. Disease management for depression and at-risk drinking via telephone in an older population of veterans. Psychosom Med 2003;65:931-7.And Coyne JC, Brown G, Datto C, Bruce ML, Schulberg HC, Katz I. The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study. Int J Geriatr Psychiatry 2001;16:570-6.And Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002;325:951-4.And Roberts K, Cockerham TR, Waugh WJ. An innovative approach to managing depression: focus on HEDIS standards. J Healthc Qual 2002;24:11-64.

27 DH Chronic Disease Management; the growing problem and strategic response 27 Case management For some patients a more holistic approach is required. They are often highly intensive users, or very highly intensive users of the health service, and simple problems amenable to early interventions (e.g. a fall or an acute infection) can lead to a rapid deterioration in their condition.

28 DH Chronic Disease Management; the growing problem and strategic response 28 It is these people that largely make up the 5% 10% of patients account for 55% of bed use 5% of patients account for 42% of bed use

29 DH Chronic Disease Management; the growing problem and strategic response 29 Case management Before Case management Initially presented in A&E 4 times over the last 3 months with falls Care package, meals on wheels and personal alarm in situ At risk of recurrent falls, poor transfer technique Unable to access community transport or mobilise outdoors Oedema in both lower legs Older person felt lonely, isolated and depressed – I tell people what I need but they dont hear me. After Case management Easy-Care Assessment in own home. Listened to her voice and spent time understanding her needs. Contacted GP and District Nurse to review medication and to deliver incontinence pads. Spent time together to ensure receiving appropriate benefits. Arranged for mobile hairdresser and for ears to be pierced. Carried out a joint assessment with the Occupational Therapist. Put air into tyres of old wheelchair

30 DH Chronic Disease Management; the growing problem and strategic response 30 How does it fit together? The Chronic Care Model

31 DH Chronic Disease Management; the growing problem and strategic response 31 PCTs need to work in partnership with other NHS Trusts (including ambulance trusts) and social care to develop integrated approaches to care. A key issue is the sharing of incentives to promote high quality care. Many of the pieces are in place: The Expert Patient programme, NHS Direct and digital TV pilots, but some is patchy. We must build on the use of evidence based guidelines for the treatment of chronic diseases and incorporate them in IT systems to make it easier to do the right thing. We should build on the strengths of multidisciplinary team working (including social care) with a strong centre in primary care. The NHS could increase its use of risk stratification and case management of high risk patients. PCTs need local strategic partnerships with local authorities, engaging community and voluntary organisations PCTs need to work in partnership with other NHS Trusts (including ambulance trusts) and social care to develop integrated approaches to care. A key issue is the sharing of incentives to promote high quality care. Many of the pieces are in place: The Expert Patient programme, NHS Direct and digital TV pilots, but some is patchy. Remember the three Rs: IT should can support care planning, risk stratification, and monitoring the quality of care on offer. Information systems need to support the transfer of information. We must build on the use of evidence based guidelines for the treatment of chronic diseases and incorporate them in IT systems to make it easier to do the right thing. We should build on the strengths of multidisciplinary team working (including social care) with a strong centre in primary care. The NHS could increase its use of risk stratification and case management of high risk patients. PCTs need local strategic partnerships with local authorities, engaging community and voluntary organisations Remember the three Rs: IT should can support care planning, risk stratification, and monitoring the quality of care on offer. Information systems need to support the transfer of information.

32 DH Chronic Disease Management; the growing problem and strategic response 32 Patient experience programme: The Expert patient programme, NHS Direct and digital TV provide resources for patients to better manage their care Set of tools in each health community to create a health and social care system to support people with a chronic problem Payment by results: Gives commissioners a means of releasing funds from acute care & encourages trusts to reduce LOS Incentive scheme to encourage social services to avoid delayed transfer of care IT: Already the information systems are in place for Registration, Recall, and Review. At risk patient can be identified. The NPfIT will augment this and help the flow of information New pharmacy contract: Allows PCTs to broaden services available in the community New GMS and PMS: The quality and outcomes framework rewards good CDM in ten important diseases. PMS+ and enhanced services gives PCTs the ability to build capacity for new chronic disease services National Service Frameworks: Many of the NSFs have obvious implications for better CDM- diabetes, CHD, older people, mental health, children, renal disease, long term neurological conditions Payment by results: Gives commissioners a means of releasing funds from acute care & encourages trusts to reduce LOS Incentive scheme to encourage social services to avoid delayed transfer of care IT: Already the information systems are in place for Registration, Recall, and Review. At risk patient can be identified. The NPfIT will augment this and help the flow of information Patient experience programme: The Expert patient programme, NHS Direct and digital TV provide resources for patients to better manage their care New pharmacy contract: Allows PCTs to broaden services available in the community New GMS and PMS: The quality and outcomes framework rewards good CDM in ten important diseases. PMS+ and enhanced services gives PCTs the ability to build capacity for new chronic disease services National Service Frameworks: Many of the NSFs have obvious implications for better CDM- diabetes, CHD, older people, mental health, children, renal disease, long term neurological conditions

33 DH Chronic Disease Management; the growing problem and strategic response 33 Other potential tools... Use defined clinical care pathway s Integrat e with social care, more inter- mediate care Ensure savings made in one part of the system benefit all involved in chronic care Commissio n care through clinical networks Develop communit y clinical specialist (nurse led) teams Practice incentives and commissionin g Use defined clinical care pathway s Integrat e with social care, more inter- mediate care Ensure savings made in one part of the system benefit all involved in chronic care Commissio n care through clinical networks Develop communit y clinical specialist (nurse led) teams Practice incentives and commissionin g

34 DH Chronic Disease Management; the growing problem and strategic response 34 Health care communities and the NHS as whole benefit because investing in chronic disease reaps health and financial dividends. The Wanless report, Securing Our Future Health (Interim Report) argued that for every pound invested in self care; The economic case for disease management is more complex, but the improvement in quality of life is undeniable. There is a growing evidence base on the possible financial effects of case management (mainly from abroad, but increasingly from the UK). This suggests that investing in primary and community care to support case management will free up scarce acute resources to use more appropriately. around £1.50 can be reinvested more effectively

35 DH Chronic Disease Management; the growing problem and strategic response 35 The NHS moves from… EFFECTIVE CHRONIC DISEASE MANAGEMENT

36 DH Chronic Disease Management; the growing problem and strategic response 36 But most importantly, patients benefit... Control of their own condition Feeling of well being Ability to cope day to day Complications from their chronic disease Unnecessary hospital admissions Sense of powerlessness


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