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Presentation on theme: "CHRIS DOWSE PROGRAMME LEAD CHRONIC DISEASE MANAGEMENT."— Presentation transcript:


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

3 CASTLEFIELDS HEALTH CENTRE (UK) 15% reducn unplanned admissions 31% reducn 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% reducn urgent care visit rate 50% reducn hospital bed days

5 EVERCARE (USA) 50% reducn 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 popn = 30% unplanned admissions for that age group many admissions avoidable (urinary tract infection, dehydration) 55-87% high risk popn 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. Reducn occupied bed days % = up to £1.15m for PCTs

8 NW LONDON SHA (cont) Reducn A&E adult attendances 2-3% Reducn 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 Deal with Acute Attack of Disease Counsel re: Lifestyle Changes Review Labs Access Social/Other Services Reassure Diagnose General Referral Reviwe/Adjust Rx and Tx Routine Preventive Care Modify and/or Negotiate Care Plans Review History Review Care Plan Complete Forms Talk with Family Reinforce Positive Health Behaviours Traditional 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 Chronic Care Model Consultation 10 minutes Source: KPCMI [21]

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

11 COMPONENTS OF EFFECTIVE CDM (1) Popn 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 popn within PC Move to popn mgt - stratify for risk Improve disease mgt: Care Plans; review/ recall/ reassessment; care co-ordination Support self management throughout Identify popn with highest burdens of disease [ 2+ unplanned admissions; 4+ meds; etc] Apply case mgt principles - proactive care


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