1. CHRONIC DISEASE MANAGEMENT
CHRIS DOWSE
PROGRAMME LEAD
CHRONIC DISEASE MANAGEMENT

2. Learning and evidence so far
What is a systematic approach to CDM?
Getting started

3. CASTLEFIELDS HEALTH CENTRE (UK)
15% reduc’n unplanned admissions
31% reduc’n hospital LOS (6.2 to 4.3)
Total hospital bed days fell by 41%
Significant savings
Better patient experience
Improved integration + more appropriate referrals

4. VETERANS ADMINISTRATION (USA)
35% reduc’n urgent care visit rate
50% reduc’n hospital bed days

5. EVERCARE (USA)
50% reduc’n unplanned admissions without detriment to health
Significant reductions in medications
97% family and carer satisfaction
High physician satisfaction

6. NHS-ADAPTED EVERCARE
3% of target pop’n = 30% unplanned admissions for that age group
many admissions avoidable (urinary tract infection, dehydration)
55-87% high risk pop’n not accesssing DNs & Social Services
polypharmacy

7. NW LONDON SHA Case mgt releases significant capacity
29% total medical specialities bed days used by 65+ with 2+ unplanned admissions.
Reduc’n occupied bed days %
= up to £1.15m for PCTs

8. NW LONDON SHA (cont) Reduc’n A&E adult attendances 2-3%
Reduc’n GP activity for 75+ up to 53% home visits; 82% OOHs; 19% general appts.
To set up case mgt - £173k per PCT

9. THE TRANSFORMATION Traditional Model Chronic Care Model
SICKNESS CARE MODEL (Current Approach - Physician Centric)
Care is Proactive
Care delivered by a health care team
Care integrated across time, place and conditions
Care delivered in group appointments, nurse clinics, telephone, internet, , remote care technology
Self-management support a responsibility and integral part of the delivery system
Counsel re: Lifestyle Changes
Deal with
Acute Attack
of Disease
Review Labs
Reinforce Positive Health Behaviours
Access Social/Other Services
Talk with Family
Reassure
Complete Forms
Diagnose
Review Care Plan
General Referral
Consultation 10 minutes
Reviwe/Adjust Rx and Tx
Review History
Routine Preventive Care
Modify and/or Negotiate Care Plans
Source: KPCMI [21]

10. Population Management: More than Care & Case Management
Targeting Population(s)
Redesigning Processes
Measurement of Outcomes & Feedback
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 1
70-80% of a CCM pop
Level 2
High risk members
Level 3
Highly complex members

11. COMPONENTS OF EFFECTIVE CDM (1)
Pop’n management & risk stratification
Effective registers and integrated records
Evidence based “care pathways”
Disease management and care co-ordination

12. COMPONENTS OF EFFECTIVE CDM (2)
Self care/self management - with information and support
Active management of at risk patients
Primary/secondary/social care co-ordination

13. KEY PRINCIPLES OF CASE MGT.
Enhancing PC team role thro’ multi-disciplinary approach Stratifying patients for highest risk
Providing proactive care to patients with highest burdens of disease

14. KEY PRINCIPLES OF CASE MGT.
Professional, usually clinical, case managers co-ordinating Care Plan
Working across boundaries and in p/ship with secondary care clinicians and social services
Care Team managing patient journey proactively and seamlessly thro’ all parts of health & social care system.

15. BE SYSTEMATIC - GETTING STARTED
Identify CD pop’n within PC
Move to pop’n mgt - stratify for risk
Improve disease mgt: Care Plans; review/ recall/ reassessment; care co-ordination
Support self management throughout
Identify pop’n with highest burdens of disease [ 2+ unplanned admissions; 4+ meds; etc]
Apply case mgt principles - proactive care