Layering on Non-Communicable Diseases The AMPATH Chronic Disease Management (CDM) Program

Jemima Kamano, MBChB, MMEDTeam Leader, AMPATH CDM Program

Rationale

High burden of Non-Communicable Diseases (NCDs) in Kenya but no working systems to address them.

Both HIV and NCDs are chronic diseases. The AMPATH HIV program is an example of a successful chronic disease model.

Early diagnosis and sustained care are key to successful treatment and prevention.

They share the “tip of the iceberg syndrome” (a very small proportion of the total affected mass are in care at any one time)

Prevention strategies are possible and play a key role. Treatment is expensive, failure to treat is even more devastating.

Layered Programs Within AMPATH:Potential for integration

Traditional AMPATH

PHCT/FLTR (Find, Link,

Treat ,Retain)

Primary Health

Care (PHC)

NCD

Facility-basedHIV care

Decrease incidence HIV>50%Mother to Child Transmission

(MTCT) <5% in catchment

Decrease maternal, infantand under 5 mortality >50%

Level 1-6 care for cancer,hypertension, diabetes,lung disease and mental

disorders

A

B

C

D

OVC/Community Health Worker (CHW)

in some locations

Perpetual Home-based Counseling and Testing

(PHCT): HIV: Find and LinkCBOW: HIV: Retain and Pregnant: Find and Link

OVC/CHW

PHCT: HIV: Find and LinkCHW: Kenya Essential

Package for Health (KEPH); Pregnant: Find and Link;

HIV: Retain; OVCCommunity Health Extension Worker (CHEW): oversight

PHCT: HIV and NCD find and Link

CHW: as in C plus. Help with NCD Link and Retain

CHEW: oversight

Community-based staff and their primary role

Program Design and Implementation FLTR: case Finding, Linkage, Retention

and Treatment are the cornerstones. Case finding done through

incorporating blood pressure and random blood sugar test into the existing PHCT program initially developed for HIV.

Linkage and retention in care done through the community strategy model of PHC.

Treatment systems utilizes the AMPATH HIV clinics converting them to chronic disease clinics.

Program Design

High disease burden, called for innovation hence the use of level 2 facilities for confirmation of diagnosis, triage and care for early disease for NCDs.

An efficient referral system very critical for successful NCD programs, hence additional effort placed in building Centers of Excellence (COEs) at the referral hospital and mini-COEs at level 4 facilities.

Multiple stakeholders in this design with government being a major partner for sustainability.

Key Innovations

Change from patient finds Doctor, to Doctor finds patient.

Task-shifting – policy is to have physicians treat NCDs, in this model nurses and Clinical officers are key providers.

Medical records- from paper forms to electronic medical records―great opportunity for quality control and feedback, summary sheets etc .

Use of hand held devices- gives opportunity for real time decision support, eases work load.

Program Roll Out

Program Roll Out: The Milestones

1. Over 100 nurses and clinical officers trained in diabetes and hypertension care.

2. Over 1500 adults screened for diabetes and hypertension so far in the pilot community units.

3. Hypertension and diabetes care set up in 17 dispensaries

4. Integration of Diabetes, Hypertension and HIV care operationalized: From CCCs to Chronic Disease Clinics (CDCs) in 2 centers.

5. Training and Piloting of clinical decision support use ongoing.

Opportunities for Further Partnership

Opportunity to expand to more AMPATH sites (currently limited by funding).

Opportunity for diagnostics support i.e. laboratory and others especially for COE level.

Staffing challenge- very stretched work force, need to identify donor partners willing to sponsor some staffing positions for a given time.

Training opportunities- development of important competencies such as diabetes educators.

Data transmission- challenge of cost. Looking for partnerships with mobile providers to give better rates.

Need for partnership in developing efficient staff motivation strategies - cross cutting.

Thank You For Your Support!