SGeneral Principles of Good Chronic Care
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Transcript of SGeneral Principles of Good Chronic Care
General Principles of good chronic care
Dr Samita AcharyaAssistant Professor
PAHS
Chronic conditions
• Any condition that requires ongoing adjustments by the affected person and interactions with the health care system.
Differences Between Acute and Chronic Conditions
ACUTE CHRONICBeginning Rapid Gradual
Cause Usually one Many
Duration Short Indefinite
Diagnosis Commonly accurate
Often uncertain
Diagnostic tests
Often decisive Often limited value
Treatment Cure common Cure rare
Differences Between Acute and Chronic Care Roles
ACUTE CHRONICRole of Professional
Select and conduct therapy
Teacher/coach and partner
Role of Patient
Lorig 2000
Follow orders Partner/ Daily manager
Chronic Illness in Nepal
• Despite annual spending of well amount of money by patients and significant advances in care, one-half or more of patients still don’t receive appropriate care.
• Gaps in quality care lead to thousands of avoidable deaths each year..
• Patients and families increasingly recognize the defects in their care.
Why are we doing so poorly?
• “The current care systems cannot do the job.”
• “Trying harder will not work.”
• “Changing care systems will.”
Why we are not efficient in managing chronic conditions?
• Rushed practitioners not following established practice guidelines.
• Lack of care coordination.• Lack of active follow-up to ensure the best
outcomes.• Patients inadequately trained to manage their
illnesses.
Why is it important to manage chronic illness well?
• Patients suffering from major chronic illnesses face many obstacles in coping with their conditions,its just not the medical care that often does not meet their needs but psychological support, and information.
What Patients with Chronic Illnesses Need
• A “continuous healing relationship” with a care team and practice system organized to meet their needs for:
Effective Treatment (clinical, behavioral, supportive), Information and support for their self-management, Systematic follow-up More intensive management for those not meeting targets, and Coordination of care across settings and professionals
CCM defines six elements whose coordination is necessary for quality disease management
• Community resources• Health system• Self management support• Delivery system design• Decision support• Clinical information systems
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformationSystems
Self-Management Support
Health System
Resources and Policies
Community Health Care Organization
Chronic Care Model
What distinguishes good chronic illness care from usual care?
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice Team
Assessment of self-management goal attainment and confidence as well as clinical status
Adherence to guidelinesTailoring of clinical management by stepped protocol (Treat to
target)Collaborative goal-setting and problem-solving resulting in a
shared care planPlanning for active, sustained follow-up
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice Team
How would you recognize aproductive interaction?
What characterizes an “informed, activated patient”?
Informed,ActivatedPatient
They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.
What characterizes a “prepared” practice team?
PreparedPractice Team
Practice team and interactions with patientsorganized to help patients reach clinical targets and self-management goals..
Self-Management Support
Goal
To help patients take a more active role and be
more competent managers of their health and
healthcare.
Community Resources and Policies
Goal
To help patients access effective and useful services
and resources in the surrounding community.
Delivery System Design
Goal
To organize practice staff, schedules and other
systems to assure that all patients receive
planned, evidence-based care.
Decision SupportGoal
To assure that clinicians and other staff have the
training, scientific information and system
support to routinely provide evidence-based
(adhere to guidelines) and patient-centered care.
Clinical Information System
Goal
To assure that clinicians and other staff have ready
access to patient information on individuals and
populations to help plan, deliver and monitor
care.
Health Care Organization
Goal
To assure that practices within the organization
have the motivation, support and resources
needed to redesign their care systems.
FACTS AND FICTIONS1. Diabetes is the leading cause of adult blindness,
amputations and kidney failure. True or false?
________________________________________A. False. Poorly controlled diabetes is the leading cause of adult
blindness, amputations and kidney failure.
Symptom Cycle
Vicious Cycle
Disease
Tense musclesFatigue
Depression
Anger/Frustration/Fear
Stress/Anxiety
The Patient-Focused Approach
BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.
KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management
General principles of good chronic care
• These principles can be used in managing many diseases and risk conditions.1. Develop a treatment partnerships with your
patients.2. Focus on your patient’s concerns and priorities.3. Use the 5 A’s:Assess,Advice,Agree,Assist and
Arrange4. Support patient self management.5. Organize proactive follow up
6.Involve “expert patients” ,peer educators and support staff in your health facility.
7.Link the patient to community- based resources and support.
8.Use written information-registers,treatment plan, treatment cards and written information for patients- to document, monitor and remind.
9.Work as a clinical team.10.Assure continuity of care.
Coordinated approach to chronic care
• To achieve good chronic care, community partners, health care team ,patients and families should always be prepared, informed and motivated.
Community partners
• Support patient goals and action plans.• Provide care and support to patient and family.• Provide resources to support patient self -
management, including peer support groups.• Function as treatment buddies.• Link with health care team and follow-up
periodically.(screening,health camp)• Advocate for policies to improve care
Health care team
• Elicit patient’s concerns.• Assess patient’s clinical condition, perform in
depth assessment ,diagnose.• Assess readiness to adopt indicated
treatments.• Exchange information about health risks.• Elicit patient’s goals for care.• Collaboratively agree upon treatment plan
Contd
• Refer for further diagnostic work and treatment plan, if indicated.
• Arrange for agreed follow-up.• Reinforce patient’s self-management efforts.• Involve peer educators/expert patients.• Link with community partners and follow up
periodically.
Patients and families
• Presents concerns.• Discuss goals with provider.• Negotiate a plan of care with provider /team• Self -monitor key symptoms and treatments.• Return for follow –up according to agreed
plan.
5A’s of chronic care consultation
• Assess – Asses patient’s goals for this consultation.– Asses patient’s clinical status, classify/identify relevant
treatment .– Asses risk factors that can lead disease or make it
worse– Asses patient’s knowledge, beliefs,concerns,and daily
behaviors related to chronic condition and treatment.– Asses that your patient ever tried a behavioral
modification or not .
Advise
• Use neutral and non-judgmental language.• Correct any inaccurate knowledge and
complete gaps in the patient’s understanding of conditions or risk factors and their treatments.
Agree
• Negotiate selection from the different options.• Agree upon goals that reflect patient’s priorities.• Ensure that the negotiated goals are:
– Clear – Measurable– Realistic– Under the patient’s direct control– Limited in number
Assist
• Provide a written or pictorial summary of the plan.
• Provide skills and tools to assist adherence.• Provide adherence equipment that is easy to
understand – You can arrange medicine box by day of week– Self monitoring tools( using calendar to remind
and record treatment plan)
• Address obstacles• Provide psychological support as needed
– Help patients to predict possible barriers to implementing the plan and to identify strategies to overcome them.
– If patient is depressed ,treat depression• Link to available support
– Friends,family– peer support groups– community services
Arrange
• Arrange follow-up to monitor treatment progress and to reinforce key messages.
• Record what happened during the visit.
Follow –up visit
• Assess– Compare assessment findings with those from
previous examination and discuss with patient.– Assess patient’s understanding of the treatment
plan.
• Assess patient’s adherence to the treatment plan(by asking, counting pills, checking pharmacy records).if there is adherence problem,its important to explore the reasons and obstacles to adherence.
• Acknowledge patient’s efforts and successes with self- management, even if they are limited.
• Advise – Repeat key information concerning the patient’s
condition and its treatment– Reinforce what patients need to self- manage
• Symptoms, when to change treatment or to seek care.• Treatment(why it is important, and adherence is
required)• How to monitor one’s own care.• How and where to seek support in the community.
• Agree – Negotiate changes in the plan as needed
• Assist– Discuss problems that occurred in adherence and
develop strategies to overcome them in future.• Arrange
– Arrange follow-up to monitor treatment progress and to reinforce key messages.
– Record what happened during the visit.
The Patient as Partner
Principles of CIS &DS
summary
• Whatever health services may offer, most of the day to day responsibilities for the care of chronic illness fall on patients and their families.
• Planners and organizers of medical care must recognize that health care will be most effective if it is delivered in collaboration with patients and their families.
• Health provider must practice evidence based medical treatment .
• To enable patients to play an active role in their care improve patients' knowledge and self management skills.
• Always apply 5A’s in your patient so that you can better– asses knowledge,beleifs and behavior– advice that has scientific evidence– agree on goals that are important to patients– assist by identifying barriers and strategies to overcome.– arrange continuity of care
•Thank you