CHRONIC DISEASE MANAGEMENT CHRIS DOWSE PROGRAMME LEAD CHRONIC DISEASE MANAGEMENT

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

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

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

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

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

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 7.5 -16.6% = up to £1.15m for PCTs

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

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, e-mail, 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]

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

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

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

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

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.

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