The Chronic Care Model as a vehicle for the development of disease management in Europe Professor Cor Spreeuwenberg MD PhD Department Social Medicine Faculty of Health, Medicine & Life Sciences Maastricht University INIC-Conference Gothenburg, 6th March 2008

Content Chronic Diseases Some care approaches The Chronic Care Model US and Europe Conclusions

Chronic diseases: world wide

Chronic Diseases disaster or blessing?

Aims of chronic care prevention or delay of manifestation(s), where possible improved functioning of patients - reducing symptoms and complications - prolonging lifespan - improving quality of life - living independently - according own needs, demands and preferences effective, efficient and safe health care delivery

Challenges of chronic care access prevention & lifestyle integrated care effective and efficient care (delivery) co-morbidity and multi-morbidity tailoring to the needs of patients support of self-management organization on different levels care management support manpower

Do we treat all aspects effectively? Results of systematic approach of people with diabetes (N= ) at T0, T12, T24

Lessons Supporting practitioners to improve their medical skills seems to be more effective than paying attention to behavioural interventions However 1. There are al lot of indications that most practitioners are not skilled in applying behavioural interventions 2. Behavioural interventions require different approaches, time-sets and ways of patient involvement

Approaches to improve chronic care quality: integrated care efficiency: disease management outcomes:Chronic Care Model Question: do these approaches exclude each other?

Integrated care - definition WHO (Gr ö ne, Garcia-Barbero), presented on IJIC-conference in Strassbourg, 2002 Integrated care is the bringing together of - inputs, delivery, management and organization of services - related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, user satisfaction and efficiency

Integrated care (Kodner/Spreeuwenberg, 2002) pragmatic definition: a step in the process of health systems and health care delivery becoming more complete and comprehensive contains a coherent set of methods and models on funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure/ care sectors aims to enhance quality of life, consumer satisfaction and system efficiency for patients with complex, long-term problems cutting across multiple services, providers and settings

Disease Management - definition according to DMAA (2004) a system (of) coordinated health care interventions and communications (for) populations with conditions (in which) patient self-care efforts (are) significant

Disease management background originally an American concept one disease or health problem feedback mechanism based on management information focus on efficiency more than on quality population orientation programmatic, systematic approach usually organized by a third party

2007: DMAA changed its name to Care Continuum Alliance care continuum includes strategies such as - health and wellness promotion - disease management and - care coordination Care Continuum Alliance promotes the role of population health improvement in - raising the quality of care - improving health outcomes and - reducing preventable health care costs for people with - or at risk for developing – chronic conditions

The Chronic Care Model

Chronic Care Model: Aim To improve functional and clinical outcomes by relating processes on different levels - - patient - - practice team - - organization responsible for the practice team - - health care system - - society

Chronic Care Model: central issue Creating a productive set of interactions between patient and practice team

“Informed, activated patient” Application of principles of citizenship: patient as ´owner’ of the disease understands principles of treatment able to make informed choices able to cope with relevant technology knows signs/symptoms of complications knows who to call for support active in preparing the next consultation This is an intention, but keep in mind that not all patient are capable to act on this way!

Self-management

Support of Self-management - information and education of patients -

‘’Prepared and pro-active practice team’’ Competence in clinical care, attitude, organization and communication up-to-date knowledge and skills multi-disciplinary team accessible and transparent ready to support and to inform front- and back office co-operation issues delegation of tasks, if justifiable application modern technology

A Network Information and Collaboration System Patient Personal Health Management Personal Health Record Self management Patient education Protocols ProcessesDocumentation Forms Population management Outcome management Decision support Screening Monitoring Benchmark rapports General Practitioner Researcher Practice nurse Medical specialist Psychologist Dietician PhysiotherapistPodotherapist Geriatrist

Chronic Care Model: related components or conditions Community-level:. resources and policies Health care delivery system-level. health care organization. delivery system design Practitioners/team-level. clinical information systems. decision support. self-management support

Evidence based strategies with high success factors Support of self-management - preventive messages (web etc.) - self care education Practice-level: - disease registries to identify and track people - risk stratification models - services in community settings Substitution from physicians to nurses

Europe: its health systems and chronic care approaches EU or related position health care national issue nationalized and mixed public/private systems various ways of organization various approaches to market mechanisms various ways of chronic care management cf Ellen Nolte

Europe: disease management and Chronic Care Model: general picture much support for CCM disease management initiatives independent from nature health care system disease management approaches compatible with CCM-model discussions within governments about their role in implementing disease management success also dependent of role of professionals

Converging of American and European chronic care approaches stratification based on complexity and patient features continuum of care connectivity of personal, practice and system levels prevention - and lifestyle influencing support of self-management availability and interconnectiveness of information quality control and improvement mechanisms improved functioning of the health care team information technology

Example: Stratification US-Kaiser NL - Matador Permanente Highly complex patients: Highly complex patients - Intensive case management - medical specialists High risk patients: Moderate complex pts. - Disease Management - specialized nurses Vast majority of pts: Non-complicated pts. - Supported self-care - practice nurses/GPs ____________ ________________________

From challenges to changes Implications: - organisational - status and tasks of professionals - educational - financial Implications of change are significant, but the implications of not changing are even more significant

Chronic Care Model (its principles) as a vehicle for disease management approach DM-approach: - provoked by new health legislation (2006) - intended for all chronic diseases with important prevalence, starting with diabetes - new entities, often regional embedded, which function as organizer and contractor - most entities formed by GPs - insurers supposed to set the rules - entities subcontract concrete caregivers - data gathering bij a national institute (RIVM) - starting problems (ICT) - at this moment weak attention for CCM-aspects

Opportunities to integrate disease management approach with CCM - development of care standards (how to use guidelines in daily practice) - subjects:. diabetes, COPD, cardiovascular risk management. to be developed: heart failure, depression etc.. newly written care standards take CCM as starting point - Conclusion: CCM can function as a vehicle to introduce a adapted way of disease management

Main messages The CCM can be successfully combined with a diseases management approach Care patterns must be based on complexity of health problems and readiness of patients for self-management The nature of chronic diseases, together with the upcoming shortage of staff, require a combined effort of all involved to develop powerful systems of self-management Care standards based on CCM may function as a vehicle to start with a European variant of disease management DM-organizations that mainly serve the interest of regional practitioners, may hinder the effectiveness and quality of chronic care in that region -> I thank you very much