CHRIS DOWSEPROGRAMME 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

Deal withAcute Attackof Disease

Counsel re: Lifestyle ChangesReview

LabsAccess

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, e-mail, remote care technology

• Self-management support a responsibility and integral part of the delivery system

Chronic Care Model

Consultation 10 minutes

Source: KPCMI [21]

Population Management: More than Care & Case Management

Intensive

or Case Management

Assisted Care or Care Management

Usual Care with Support

Level 170-80% of a

CCM pop

Level 2High risk members

Level 3Highly complex members

Targeting Population(s)

Redesigning Processes

Measurement of Outcomes & Feedback

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