applying the chronic care model to health system redesign in uganda the chron… · ·...

7/24/2015 1

Applying the Chronic Care Model to Health

System Redesign in Uganda

• Godfrey Kayita – STD / AIDS Control Program - MOH Uganda

• Humphrey Megere – URC/USAID Healthcare Improvement Project

• Kedar Mate – Institute for Healthcare Improvement

• Suzanne Gaudreault – URC/USAID Healthcare Improvement Project

USAID HEALTH CARE IMPROVEMENT PROJECT

Seminar Outline

• The Chronic Care Model: Why it is needed and its application at the facility level – Suzanne Gaudreault

• Chronic Care at the national level – Kedar Mate

• The challenge of providing care for Chronic Diseases like HIV/AIDS, TB, DM, HTN and other chronic conditions in Uganda 2010 Chronic Care Conference in Kampala –Godfrey Kayita

• Implementation of the Chronic Care Model in Uganda –Humphrey Megere

2

7/24/2015 3

The Chronic Care Model: Why it is Needed and its Application at the Facility

Level

Suzanne Gaudreault – URC/USAID Healthcare Improvement Project

3


Acute vs. Chronic CareAcute Chronic

Visit frequency When sick Varies by illness

Visit content Single Assessment, Diagnosis & Treatment

Recurring assessments, Ongoing treatment, Lifestyle/prevention

Provider-patient Relationship

Less important Communication, trust very important

Self-management Limited Extensive

Recordkeeping Long term record not necessary

Long term record essential

Family & community support

Short-term Lifelong


Why do health systems need to be redesigned?

• Low resource health systems are designed for Acute Care

• Treating chronic illnesses in systems designed for acute care contributes to:

– Poor coverage

– Poor retention in care

– Poor self-management of disease

– Poor clinical outcomes

– Demotivated health workers

– Poor health of people with chronic conditions; psychosocial and

economic consequences, etc.

Chronic Illness


The Chronic Care Model

6


Self-Management

Ability of patients with chronic illnesses, in

collaboration with their health care providers and

other support structures such as family and

community, to manage the symptoms, treatment,

lifestyle behavior changes, and the many

physical and psycho-social challenges that they

face each day PATIENT EMPOWERMENT


What do empowered patients do to self-manage?

• Learn about their disease• Know the consequences of poor treatment

adherence

• Seek medical care and advice when needed

• Communicate effectively with health workers

• Actively partner with providers in decision-making

• Self-monitor symptoms and follow treatment directions

• Practice health-enhancing behaviors

• Use family, peer, and community support resources

• Work to maintain emotional and psychological balance


7 Basic Components of Self-Management Support

1. Provide information about the chronic condition

2. Encourage active participation in managing the condition

3. Teach skills specific to the condition

4. Negotiate actions to achieve and maintain good health

5. Teach problem-solving skills

6. Address emotional impact of the condition

7. Facilitate use of supportive community resources

9

Tom Bodenheimer, Helping Patients Help Themselves: How to implement Self-Management Support www.chcf.org, 2010


Self Management Support in Chronic Illness Care

Informed Activated Patient

PreparedProactive Team

Productive Interactions

“Continuous Healing Relationship”


Community

• Strengthen community linkages to facilities:– Community and Faith Based Organization– Village Health Team (VHT)– Support groups– Income-generating groups– Mosques and churches– Others

• Strengthen self-management support activities in community structures including support groups

• Lobby for health policy and system changes

11


Delivery System Design

• Define roles and definitions of HCWs

• Community workers and peer supporters/expert patients, and other cadres on health care teams

• Introduce Triage

• Planned patient interactions

• Adapt home-based care to the chronic care needs of HIV patients

12


Decision Support

• Evidence-based guidelines embedded into documentation

• Provider education

• National guidelines

• Job aids

• Specialist and primary care expertise

13


Clinical Information System

• Unified documentation

• Patient subpopulation registries

• Reminders for patients and HCWs

• Monitoring and Evaluation

14

7/24/2015 15

System Redesign for Chronic Care at the National Level

Kedar Mate – Institute for Healthcare Improvement

15


Design for Chronic Care at a National Level

• All systems provide acute to chronic care– Acute care = Premium on time; provider-driven– Chronic care = Premium on partnership; patient-

driven; provider-supported

• Most health systems start with emergency response / acute care

• Countries needs guidance both in rich & poor alike


Methods

• Reviewed existing frameworks:– WHO Health Systems

Framework– MacColl Institute Chronic

Care Model– WHO Innovative Care for

Chronic Conditions


WHO Adaptation Chronic Care Framework 2002


• Self Management• Delivery system

design• Clinical Information• Decision Support• Community

Resources & Policies


Macro-level Change Ideas

WH

OH

SS B

uild

ing

Blo

cks

CCM Elements

Self Management Support (SMS)

Decision Support (DS)


Clinical Information Systems

(CIS)

Community Resources and

Policies

Human Resources

• Make available staff whose main

responsibility is SMS (existing cadre or new

cadre)

• Pre-service training on SMS

• Career development plan for those involved

in SMS

• Supervision and mentoring for SMS

• Staff hotlines to answer

difficult clinical questions

• Training and support to use

decision supports

• Focus on multi-disciplinary

team work

• Team based training

• Curricula in professional

schools focus on team work

and chronic care

• Redefine correct staffing mix

• Train and support staff

to manage CIS (new or

existing cadre)

• Form, train and support

community based

health workers (CHW)

• Policies to allow CHW

to provide support

Information Technology

• Changing medical records to include

longitudinal information on self management

• Develop and distribute

guidelines and job aids

• Include reminders in IT system

• IT designed to work in team

setting

• Developed to meet needs or

patients and providers

• Develop CIS system

for chronic conditions

care

• Develop information

system that can be

used in community and

links between

community and facility

Financing (Purchasing)

• Provide resources to train and support SMS

staff

• Procurement and distribution of SM materials

(e.g. pill boxes, home glucometers)

• Build counselling areas in facilities

• Allocate funds for decision

support

• Allocate funds to redesign

delivery systems to meet

needs of patients with

chronic conditions

• Fund CIS system for

chronic conditions care

• Fund community

supports (staff,

transport, materials,

patient resources)

Supply Chain

• Procure and distribute SM materials (e.g. pill

boxes, home glucometers)

• Procure and distribute

guidelines, job aids and other

decision support tools

• Redesign for reliable drug

and supplies availability

• Procure and distribute

CIS materials

• Include community sites

as distribution points

Leadership & Governance

• Involvement of patients in leadership and

governance

• Modelling of good relationship between

patients and providers

• Professional organizations embrace SMS

• Leadership in other sectors to incentivize

healthy behaviours

• Professional societies involved

in DS tool development

• Patient advocates involved in

DS tool development

• Modelling of teamwork by

professional organizations,

government, senior

managers

• Encourage use of data

by patients and

providers as well as

central MoH

• Involve community in

leadership roles

• Increase focus on

demand creation


Example #1: Changes to the health system necessary to deliver self-management services

Human resources Information technology

Finance Supply chain Leadership

• Make available staff whose main responsibility is SMS (existing cadre or new cadre – expert patient)


• Career development plan for those involved in SMS


•SM data included in patient records

•Longitudinal medical record that tracks SM data

•Paymentreform: Insurance schemes encourageuse of SMS

•Privatecounselling rooms in facilities

•SM supplies included in procurement•Pill boxes•SM Diaries•SM home mgmt decision support

•Leaders modellingincreased involvement of patients

•SMS recognized by professional organizations

•Leadership in other sectors emphasize SMS behaviors


Example #2: Changes to the health workforce to deliver integrated CC services

Self Management Support

(SMS)

Decision Support

(DS)


Clinical Information

Systems(CIS)

Community Resources

and Policies

• Make available staff whose main responsibility is SMS (existing cadre or new cadre – expert patient)


• Career development plan for those involved in SMS


• Staff hotlines to answer difficult clinical questions

• Training and support to use decision supports

• CC Job Aids/Tools/ Checklists

• Focus and create multi-disciplinary teams;empanel pts

• Curricula in professional schools focus on team work and chronic care

• Redefine correct staffing mix

• Train and support staff to manage CIS with longitudinal records(new or existing cadre)

• Developmentpartners change CIS to manage chronic disease

• Form, train and support community based health workers (CHW)

• Policies to allow CHW to provide support


Summary

• All countries battle transitions from acute “diagnosis” and “output” driven systems to chronic “management” and “outcomes” driven systems

• Broad coalitions will be necessary

• All models are wrong, some are useful» Box, George E. P.; Norman R. Draper

(1987).

• Needs more testing and prototyping

7/24/2015 25

The Challenge of Providing Care for Chronic Diseases in Uganda

and the 2010 Chronic Care Conference in Kampala

Godfrey Kayita – STD / AIDS Control Program - MOH Uganda

25


Population: 32,369,558

Pop. Growth Rate ~ 2.69%Per capita ~ $490Per capita (Health) ~ $12 (Abuja $15)Life Expectancy ~ 52.72PLHIV ~1,200,000 [adults]PLHIV ~100,000 [children] Adult Prev. ~ 6.4 %Children Prev. ~ 1.5%TB/HIV prev. ~ 56%HIV/TB prev. ~12%

26 26

Uganda Background


Current status of chronic care in Uganda

• WHO guidelines-based IMAI and IMCI guidelines used for adult and pediatric care present primary care chronic management approach to HIV

• Apart from HIV and TB care, true chronic disease care is limited to regional hospitals and a few district hospitals (sickle cell disease, diabetes, hypertension, cardiac disease)

• Health care training and service delivery continue to focus on infectious and parasitic diseases


May 2010 Uganda Chronic Care Design Meeting: Objectives

• Identify elements of the Chronic Care Model applicable to Uganda

• Develop an approach to integrating these elements in a prototype district

• Make MoH recommendations for Chronic Care

28


Uganda MOH Recommendations on Chronic Care:

1. Demonstrate commitment to a health system for chronic as well as acute illnesses:– Prioritize resources (material and human)– Communicate commitment to improving CC care

2. Develop and test a model based on chronic care principles using HIV as an example:– Demonstration projects

3. Strengthen & support existing health system entities:– Village Health Teams– Expert Patients– Health Unit Management Committees


Uganda MOH Recommendations

4. Support health care providers, patients, and communities to carry out roles effectively:– Work as teams to deliver chronic health care and prevention– Community education about prevention and CC care– Partner with health education schools to sustain this effort

• Chronic Care Curriculum

5. Develop a Health Information System which:– integrates all levels and types of care into one health record– allows providers to see the health outcomes of their patients– generates accurate data to evaluate and improve programs

7/24/2015 31

Implementation of the Chronic Care Model in

UgandaHumphrey Megere – URC/USAID Healthcare Improvement

Project

31


Buikwe District

• Central region• 407,100 population• Facilities

– 5 hospitals– 10 Health Centre III

Kampala

Buikwe


Baseline assessment at Nyenga Hospital


Baseline results from Uganda: Elements of the Chronic Care Model

0

10

20

30

40

50

60

70

80

90

100

Pt know drugnames

Pt know treatmentis life long

Pt aware of sideeffects

Pt can get supportfrom family

Pt can get helpfrom the facility

%

of

patients

Patient self-management

%HIV %TB %DM %HTN


Facility level care systems to improve self management

‘Patients with HIV and TB have special days and special health workers. For me when I come, I line up for long with the other patients and I don’t get time to discuss my problems. I just get drugs and I go. I want to know why I get injections and not tablets like HIV patients.’ Diabetic patient of Nkokonjeru \Hospital

‘We see HIV patients every month. But patients with diabetes come when they are sick.’ Health provider of Buikwe hospital

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

dedicated stafffor patienteducation

dedicated staffto help

patients solveproblems

separate stablepatients from

the sick

Facilities

HIV TB DM HTN


Availability of patient monitoring tools at facilities

36

0

20

40

60

80

100

HIV TB DM HTN

facilities

individual longitudinal patient records disease specific registries


Availability of mechanisms to support good clinical decisions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HIV TB DM HTN

facilities

guidelines available SOPs availableuse reminders access specialist


Chronic Care Model Prototype: Progress to Date

• Baseline assessment• 1st Improvement Collaborative Learning Session to

introduce Chronic Care Model.• 1st coaching visit: coaching teams composed of

HCI, MOH, and DHT (district health teams) members

• Logistics support to sites (counter books and box files to help in improving records)

• Spread diabetes medical record being used at one hospital to all the other sites.


Example Changes/Interventions: Self-Management

Knowledge• Health education talks at facilities• Handouts to patients on diabetes

Skills• Patient goal-setting introduced

Motivation• Patients participate in clinic activities


Interventions: Delivery system design

• All the sites made flow charts

• Some sites assigned Self- Management Support role to specific staff

• Some sites changed patient seating arrangement New flow chart at Buikwe Hospital


Interventions: Clinical information system

• All sites have introduced registers for specific for Diabetes and Hypertension

• Kawolo Hospital has introduced longitudinal files for diabetic patients

• Buikwe Hospital is providing free treatment books to patients

• Back of HIV care record being used to document Self-Management interventions

New diabetic register


Decision Support Tools


Other changes

• Formation of Chronic Care QI teams

• Reduction of user fees for patients with Diabetes and Hypertension (HIV care was already reduced or free)


Way forward

• Focus on HIV initially but encourage spill over to other chronic diseases

• Re-focus on on Self Management Support: improve patient knowledge, skill and motivation. Job aids Data system on improvement in knowledge, skill and motivation 3 self-selected facilities to initially focus on identifying changes

that improve self management

• LS 2 to share changes that have led to improvement after action period of 1 month


Thank You!

DISCUSSION

45

applying the chronic care model to health system redesign in uganda the chron… · ·...

Documents