1. Integrated Service Delivery and the Role of Hospitals in Chronic Disease Management: Analytical Perspectives and the Canberra Case Study Associate Professor Paul Dugdale European Forum for Primary Care Conference Galatasary University, Istanbul September 2013 International Hospital Federation Workshop

2. Improving the response of hospitals to patients with multi-morbid chronic conditions Background and Policy Context An approach to understanding reform: Organization; Expertise; Financing. Chronic Disease Management in Canberra Hospital and Health Services Current services Efforts to integrate with primary health care

3. Fishing near Canberra

4. Improving the response of hospitals to patients with multi-morbid chronic conditions The Increasing Burden of Non Communicable Diseases Combined with current problems in service provision: – Lack of integration between primary and referral based care – Lack of access to primary care drives over-provision of hospital and referral based care Gives clear potential for health gain.

5. Burden of Chronic Disease Most of the worlds population is living longer and dying at lower rates. Leading causes of death are shifting to non-communicable diseases. Worldwide, the number of people dying from non- communicable diseases grew 30% in the 20 years to 2010. Preventive health care has resulted in more people with chronic disease (!) People are living to an older age, but partly because of this they are experiencing more ill health, reflected in disability increases in middle- and high-income countries this is due to diabetes, musculoskeletal disease, depression, CVD and stroke. In poor countries, the burden of disease is shifting too, with the burden from hypertension, diabetes has markedly increased.

6. Current problems in health service provision Without universal coverage, people with multiple chronic diseases are often the least able to afford health cover. They may have some access to primary health care, but little access to referral based specialists or inpatient care, Or access to inpatient care only in life threatening emergencies. With comprehensive access to health services, they may be subject to turf battles over whether GPs or specialists own the patient. Inter-specialist referrals may fragment care, lead to unnecessary investigations, and reduce the role of primary care physicians. In conflicts between busy inpatient units with each trying to disown the patient in emergency that clearly requires admission.

7. Current problems in health service provision hospital-centrism reduces access to primary health care In over-commercialized health systems, people with multi morbidity are particularly prone to supplier induced demand. coordination between hospitals, primary medical care and community services is difficult and inadequate. multi morbidity requires support from non-health sectors. participation in civil society is challenging, they may be effectively disenfranchised. Their reliance on carers puts strain on themselves and their carer, and there is potential for abuse. Support for carers is often lacking in health systems, even in high-income countries.

8. Potential for health gain Given the increasing burden of non-communicable disease and the sub-optimum state of health care systems, there is widespread potential for health gain through improving the way hospitals link with primary and community based care. This will require a shift on both sides from episodic care toward coordinated, tracked or managed care. Hospitals and their associated health care services will need to maximize their contribution to population health gain for patients, not just curate their acute support during inpatient episodes.

9. Doing comparative research in Canada

10. UN and WHO Policy Context Political Declaration on the Prevention and Control of Non-Communicable Diseases (UN 2011 A/RES/66/2). WHO promoting a patient-centred model to coordinate management of chronic diseases from prevention to palliative care, at all levels of the health system, across institutional boundaries (primary health care, social care in the community, hospital services, emergency care) (WHO Europe 2012)

11. Pan American Health Organization Promote integrated health service delivery networks for the organization of the response to NCDs. They recognize the increasing intensity of service delivery needed as NCDs progress and patients acquire multiple diseases; and emphasise the importance of horizontal integration between hospitals, primary health care and community services including social services through a people centred approach. (PAHO 2011).

12. Analysing Health System Reform Assemblage of the health system Organisation Expertise Financing

13. An approach to reform Knowledge developments: from disease specific to multi-morbidity studies Organisational developments: from service centred to people centred care Financing developments: from incentivizing throughput to continuity of care

14. Health system reform direction Traditional assemblage Emerging assemblage Service centred management Patient centred services Disease specific Episode incentivesUnderstanding Continuity incentives Knowledgeof multi-morbidity Reform Direction

15. Organizational Reforms Drive toward people centred models of care supported at all governance levels and recognised in accountability frameworks. Leading hospitals have expanded to offer a broader range of services, including non-inpatient referral based specialist services in medicine and allied health, satellite clinics, and community outreach services. Toward integrated management of regional hospital, primary care and community service networks.

16. Organizational Reforms The expanded footprint gives great scope to support primary health care services, and support health promotion efforts. need to reorient logistical efforts to make care efficient and coordinated from the patients point of view. Clinical information systems which operate across settings provide formidable capability.

17. Now: Data illuminates Research and Management

18. Soon: Data illuminating all of health care

19. Reforming the Evidence Base Elucidation of common risk factors for multiple diseases eg diabetes, atherosclerosis, renal disease, depression Global Burden of Disease work (Murray Gates) Guidelines for the management of common combinations of diseases involving multiple organs and specialties. New strong measures of global well-being

20. Reforming the Evidence Base Research on Wagner Chronic Care Model Research on the Burden of Healthcare Research into soft technologies – better ways of doing things, of cooperating, new systems of care, improvements in communication. Is always conducted in-vivo. Requires dialogue and negotiation with those being researched (patients as much as medical specialists).

21. Reforming Health Financing 50 years since the publication of Arrows analysis of health insurance in 1963 WHO has swung from disease programs (1950s-60s) to Primary Care and Health for All (1970s-80s) to targeted programs (MDGs) to Universal Health Coverage. UHC orients financing for care of multi-morbidity toward continuity of care. But payment mechanisms to promote this are unclear. Financing programs often cause primary and referral based care to dis-integrate.

22. Current Questions How can we accelerate integration between primary and referral based care? What structural change will drive this? Regional comprehensive care organisations? PCOs? Private sector incentives/contracts? How should movement toward UHC be linked to planned improvement in services? And what role does reform of governance in the health system play in this linkage?

23. Chronic Disease Management in Canberra Hospital and Health Services CDM Register Disease Audits CDM clinics and services Care Audits Future directions

25. Background Epidemiological and demographic transition Rising tide of chronic disease Diabetes, COPD and CHF account for the majority of the ameliorable burden of chronic disease Government made the resource allocation Someone had to pull it together on the shop floor of the health service jungle

26. Skating on Canberras thin ice

27. The CHHS CDM Register On the MacColl Assessment of Chronic Illness Care Survey, our Clinical Information System pulled the whole level of support for the Chronic Care Model down to only the Basic level.

28. CHHS CDM Register One of Canberra Hospital and Health Services clinical information systems. Patients discharged from the Canberra Hospital with Diabetes, Chronic Obstructive Pulmonary Disease or Chronic Heart Failure or received care from some of the services that participate in the Chronic Disease Management Clinical Network Includes case management information for a range of clinical services.

29. CHHS CDM Register Hospitals,like GPs, should know their CD patients and track the care provided to them. The CDM Register draws on CHHS data records – demographics, – diagnosis, – therapeutics and – Support for self management Highly compliant with eHealth and HL7 standards

30. Diabetes Management Audit 1029 CDMR patients with a HbA1c test performed since 1 January 2010, 73% had their HbA1c checked in the previous 6 months. 40% of patients had a HbA1c less than or equal to 7% Detailed, identified results provided to 12 service units, updated monthly

31. Kidney Disease Audit 2386 CDMR patients with an eGFR result since Jan 2010 69% had a result recorded for the previous 6 months 30% have at moderate or severe loss of kidney function (eGFR<60) Detailed, identified results provided to 12 service units, updated monthly

32. Nursing Team of the Year 2012

33. CDM Services Management consulting – Implementing the chronic care model – QI, Evaluation, student and registrar research projects – Budget submissions (eg Obesity Management Service) – We convene and support a CDM Clinical Network Home telemonitoring – Telemedcare monitors – Sick patients with multiple chronic diseases – Physiological stabilisation – Confidence for CD Self Management

34. Nurse-led clinics and services COPD CNC Service for frequent users of the acute care sector with COPD – education, – clinical support and – care coordination. – Smoking cessation clinic Close links to Pulmonary Rehabilitation Program Reciprocal support arrangements with Respiratory physicians

35. Nurse-led clinics and services Parkinsons Disease and other Movement Disorders CNC Service Clinics at Canberra Hospital and University of Canberra private clinic Apomorphine service with commencement in Hospital In The Home Close working relationship with Neurologists Strong support from the ACT Parkinsons Disease Society

36. Nurse-led clinics and services Heart Failure CNC Clinic – In parallel with Cardiologist Outpatients – Phone and home visit followup available Heart Failure Rehabilitation Course – Grew out of Cardiac rehabilitation course – 12 weeks of exercise and education Heart Failure Inpatient Consult Service – CDM supports cardiologists to provide this, and use it as a feeder for the CNC clinic and HF course

37. Our friendly staff will sign you on for trials, eHealth and special offers

38. Advance Care Planning Clinic All staff participate Preparatory discussions in the course of care then clinic booking made for decisions and signing Two staff, patient and carer all need to be present for legal reasons.

39. Care Coordination Service For COPD, Parkinsons and CHF Referrals assessed by CNCs Care coordinators develop Flinders Care Plans with patients Focus on patient goals linked to self management strategies, education and coordination of community and other support services Linkage to general practice is patchy

40. CD Telephone Coaching Service Telephone based service to improve self management for people with – Chronic Heart Failure, – Coronary Artery Disease, – Chronic Obstructive Pulmonary Disease – Diabetes. The service is being delivered by an We have teamed with Medibank Health Solutions Referrals or CDM Register-based patient selection Single consent process

41. CDM Performance Monitoring Detailed performance monitoring for all services Regular, one-off and research grade comparative audits for each service using the CDM Register Occasions of Service tracking from the Patient Administration System HbA1c and eGFR from ACT Pathology

42. Audit of Care Plans for 2209 patients on the CDM Register Number of participants with any care plan and with a CDM care plan Number n-2209 CDMR all n (%) CDMR other n (%) CCP n (%) Cardiac rehab n (%) TTCP n (%) Total Registered (31/03/11) 2202 (100%)1337 (61%)325 (15%)416 (19%)124 (6%) No. with any care plan 1423 (65%)839 (63%)234 (72%)236 (57%)114 (92%) No. with CDM care plan 464 (21%)216 (16%)105 (32%)45 (11%)98 (79%)

43. Type of in-scope care plan

44. Future directions We are working with the local Primary Care Organisation On integrating our Chronic Disease Management Team with their Practice Support Team Deepening our involvement with general practice to include practice managers and nurses Overcoming distrust on both sides

45. Summary Hospital Networks should know their patients with chronic disease, track and coordinate their care appropriately. Aggregate chronic disease management services to achieve critical mass, visibility and flexibility Work closely with general practitioners Build in QI, research and performance management

46. Thankyou ! Go to www.act.gov.au and search for Chronic Disease Managementwww.act.gov.au