Continuous Care in Chronic Conditions

Learning's from a project between Bispebjerg Hospital and Copenhagen Community

“Improving Care in Europe and the US: Towards patient-centered, proactive and coordinated systems of

care”

Anne Frølich, MD, Ass. Professor, Department of Health Services Research, Bispebjerg

Hospital, University of Copenhagen

Project members

• Jens Egsgaard

• Carsten Hendriksen

• Dorte Høst

• Helle Schnor

• Cecilia Ravn Jensen

Goals for the project

1. Improve care in chronic conditions focusing on continuity

2. Develop a model that support chronic care

Focus on Chronic conditions Recommendations for Improvement of Care in Chronic Conditions, National Board of Health,

Year 2005

Prevalence rates of the most common chronic conditions

COPD 200.000 4%Type 2 DM 200.000 4%CHF 200.000 4%Muscle- 200.000 4% Skeletal conditionsOsteoporosis 300.000 6%

National Board of Health – Publication with Recommendations

Patient, Healthcare and Society

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Reaching for a more Coordinated

Healthcare System

The Structure Reform:• Reduced the 14 counties to 5 regions• 278 Municipalities was reduced to 98 The new health act:• Mandatory Healthcare Agreements to avoid

fragmentation: • Focus on discharge from hospital for weak

elderly patients, agreements on social services for people with mental disorders and agreements on prevention and rehabilitation

The Local Government Reform

New Healthcare Act

One of the major changes following the new health care act is transfer of the responsibility for rehabilitation and health promotion services from the regions to the municipalities

Coordination of Care

Macro level State level, healthcare agreements between regions and municipalities

Meso level Organizational level

Micro level Patient-provider level

Methods and Material

Copenhagen Municipality: 503.000 citizens

Østerbro local area: 80.000 citizens

Bispebjerg Hospital: 700 beds and 3.500 employees

General practitioners: 57 GP’s, 50% in solo practices

Conditions: COPDType 2 diabetesHeart failureBalance problems

New Organization at the Municipality Level:

Health Center

Rehabilitation in the hospital and at the municipality level – health center

Activities in a rehabilitation unit:• Primary assessment, physical tests and quality of Primary assessment, physical tests and quality of

life testslife tests• Physical TrainingPhysical Training • Smoking CessationSmoking Cessation• Patient EducationPatient Education• Dietician Counselling Dietician Counselling • Psychosocial supportPsychosocial support• Planned follow-upPlanned follow-up

Coordination at the Organizational Level

• Coordinated leadership across sectors - horizontal and vertical cultures and goals for patient care aligned to some extend

• Disease management programs developed across sectors

• Agreed stratification of patients between sectors ex. COPD FEV1% of expected magnitude limit at 50% changed to 30%

• Use of identical measures including, diagnosis, diagnosis specific, general measures (BMI, smoking rates, etc., ), physical measures (senior fitness tests), quality of life; general and disease specific,

• Knowledge sharing meetings

• Teaching programs across sectors for nurses and therapists and for physicians

• Sharing of patient information – referrals, summary

• Follow-up either in rehab. units or in local society,

Coordination at the Patient – Provider level

• Action plans - Agreements between patient and provider for goals of the rehabilitation

• Patient education – activation of the patient

Barriers to Coordination

• Non-aligned financial incentives between sectors• Culture differences between sectors• IT-systems not able to communicate sufficiently• …….

Model for Chronic Care

Leadership

Health professionals Competences

Health professionals Competences

Health professionals Competences

Leadership

Copenhagen Municipality

General Practitioners

Bispebjerg Hospital

Coordinated Leadership across Sectors

Leadership

Coordination supported by:•Clinical guidelines•Agreed stratification of patients •Identical quality assessment measures•Knowledge sharing meetings •Sharing of patient information •Follow-up

Patient / citizen

Coordinated Leadership across Sectors

Toolbox

Patient / citizen

Patient / citizen

Thank you for your attention!

The Chronic Care Model

• Some of the best practices in the chronic care model:– Leadership– Resources– Financial Incentives– Provider Feedback– Program Evaluation– Patient Action Plans– Patient Education– Guideline Training– Provider Alerts– Electronic health record– Defined Care Path– Risk Stratification– Registry– Follow-up– Inreach– Care Coordination– Team-Based Care– Cultural Competence

From Improving Chronic Illness CareEd Wagner, MD, Group Health Cooperative of Puget Sound

Population Management Levels of Care

Specialty

Care

Assisted Care for Multiple Risk Factor

Management - Meds, Get to Goal, Lifestyle Change

Primary Care with Support -

Meds, Get to Goal, Lifestyle Change

Level 1 65-80%

PCP Care,,

Pharmacist

eCare, Web

Level 2

20-30%

Level 3

1-5%

Specialty MD CareCoordination with case/care management, eCare

Advanced DiseaseComplex Co-morbid ConditionsComplex Psychosocial IssuesFrail Elderly

Need close surveillance of symptoms, medication titration, and intensive self-management education:• Not in control•Adherence problems/ Depression•Complex medication regimen•Co-morbid conditions

Nurse or PharmD Care ManagementMA with MDeCare

•Need Medications•Under Control•Lifestyle Changes

Results

• Number of patients dived by diagnoses:

• COPD

• Type 2 diabetes

• Heart failure

• Balance problems

COPD

• Se konklusionen..

Rehabilitation units in the hospital and rehabilitation centres in the community

Patients at level 2 and some in 3 receive rehabilitation in the medical centre and patients at level 3 in the hospital

It is a demand that diagnoses and medical treatment are in place when patients are referred to rehabilitation

Activities in a rehabilitation centre: • Primary assessment, physical tests and quality of life testsPrimary assessment, physical tests and quality of life tests• Physical TrainingPhysical Training • Smoking CessationSmoking Cessation• Patient EducationPatient Education• Dietician Counselling Dietician Counselling • Psychosocial supportPsychosocial support• Planned follow-upPlanned follow-up

Model for improved continuous care

Ledelse

Personale Faglighed

Health professionals Competences

PersonaleFaglighed

Ledelse

Københavns kommuneSCØ, andre kommunale aktører

Praktiserende læger

Bispebjerg Hospital

Tværsektoriel ledelse

Leadership

Sammenhænge understøttes af:Forløbsbeskrivelser

StratificeringMonitorering

VidendelingsmøderInformationsudvekslingFastholdelse af effekt

Patient / borger

Tværsektoriel ledelse

Tool box

Patient / borger

Patient / borger

Continuous care is supported by:

• Forløbsbeskrivelser• Stratificering• Monitorering• Videndelingsmøder• Informationsudveksling• Fastholdelse af effekt

SIKS modellen

Ledelse

Personale Faglighed

Personale Faglighed

PersonaleFaglighed

Ledelse

Københavns kommuneSCØ, andre kommunale aktører

Praktiserende læger

Bispebjerg Hospital

Tværsektoriel ledelse

Ledelse

Sammenhænge understøttes af:Forløbsbeskrivelser

StratificeringMonitorering

VidendelingsmøderInformationsudvekslingFastholdelse af effekt

Patient / borger

Tværsektoriel ledelse

Værktøjskasse

Patient / borger

Patient / borger

The National Strategy for Health Promotion and Prevention Focus on

Improvements in eight Chronic ConditionsPrevalence rates of the most common chronic

conditions • Diabetes 300.000• COPD 300.000• Coronary Heart Disease 200.000• Osteoporosis 300.000• Muscle skeletal disorders 800.000 • Asthma and allergy 1.000.000• Cancer • Psychiatric diseases 100.000

The National Strategy Focus onImprovements in

Eight Chronic Conditions Diabetes type 2 COPD Cardiovascular diseases Osteoporosis Muscular and skeletal disorders Allergy Mental diseases Preventable malignancies

Background for the project

• High and rising prevalence rates of chronic conditions

• The structural reform and the new health act

New Covered Services in the Primary Care Sector

• One-year follow-up in diabetes patients (type 1 and 2) including regularly controls, recording of diagnosis to IT system, ensure patients undergo recommended screenings

Experiences from DM will be used to develop benefit models in other chronic conditions such a COPD, asthma, CHF, depression etc.

Continued – New Covered Services in the Primary Care Sector

• Prevention consultations related to life style factors such as tobacco use, alcohol, Physical activity nutrition, and Other risk factors and integrated counselling

• Home visits to frail elderly once a year• Screening for depression

Rehabilitation units in the hospital and rehabilitation centres in the community

Patients are stratified to receive rehabilitation in the hospital if the belong to level 3 and patients at level 1 and 2 in the health center

It is a demand that diagnoses and medical treatment are in place when patients start rehabilitation

Activities in the rehabilitation centers: • Primary assessment, physical tests and quality of life testsPrimary assessment, physical tests and quality of life tests• Physical TrainingPhysical Training • Smoking CessationSmoking Cessation• Patient EducationPatient Education• Dietician Counselling Dietician Counselling • Psychosocial supportPsychosocial support• Planned follow-upPlanned follow-up