Dr Jason Cheah

Chief Projects Officer

National Healthcare Group, Singapore

DISEASE MANAGEMENT:

SINGAPORE STYLE

THE COMPARTMENTALISED “ILLNESS” CARETHE COMPARTMENTALISED “ILLNESS” CARE

Pre-illness Illness Post-illness

• Clinics, hospitals • Home Care Services• Nursing Homes

• Vaccination• Public Health Education• School Health• Workplace Health Promotion

THE “HOSPITAL-WITHOUT-WALLS”THE “HOSPITAL-WITHOUT-WALLS”

Pre-illness Illness Post-illness

Health Maintenance• Vaccination• Public Health Education• Health Screening• Workplace Health promotion

Illness Care• Cost effective, efficient care

- systems processes - clinical pathways

Health Recovery• Skills-for-life• Homecare support• Follow-up support

Brief on Singapore Healthcare System

• Dual care delivery system – public and private• Co-payments and use of Medical Savings Scheme• Hospital services utlise largest portion of NHE• Funding for public hospital services by DRG (in-patient

and day surgery) and per attendance basis (specialist outpatient clinics)

• Establishment of two public sector clusters to foster vertical integration of clinical services

Megatrends

• Demographic transition – ageing population, decreasing total fertility rates

• Epidemiological transition – changing disease profiles to chronic diseases (diabetes mellitus – 9%, hypertension – 27% of adults)

• Demand for cost-effective healthcare services• Decreased information asymmetry and increased consumer

choices• Technology changes

National Healthcare Group

Outpatient facilities:

- 2 National Centres – National Neuroscience Institute (NNI) & National Skin Centre (NSC)

- 9 Polyclinics – located at various housing estates in Singapore

Inpatient facilities:

- 1 Tertiary Hospital – National University Hospital (NUH)

- 2 Regional General Hospitals – Tan Tock Seng Hospital (TTSH) & Alexandra Hospital (AH)

- 1 Specialty Hospital _ Woodbridge Hospital (WH)

Vision

Adding Years of Healthy Life to the

People of Singapore

Mission

We will improve health and reduce illness through patient-centered quality healthcare that is accessible, seamless, comprehensive, appropriate and cost-

effective in an environment of continuous learning and relevant research

Fragmentation of Healthcare System

Lower Costs Higher CostsHealthcare Spectrum

Self-directed Primary Secondary Tertiary Long Term

Preventive Strategies

Family PractitionersAllied healthprofessionals

Specialists HospitalsOutpatientClinics

Hospitals Centers of Excellence

InstitutionsNursing HomesHome Care

Clinical Integration

Objectives

• To coordinate the entire continuum of primary, secondary and tertiary healthcare services.

Clinical integration extends both horizontally and vertically.

Clinical Integration

Achieving clinical integration requires:

• Clinical leadership

• Availability of expertise

• Availability of resources

• Supportive management

Definition of Disease Management (DM)

A clinical management process of care that spans the continuum of care from primary prevention to ongoing long-term maintenance for individuals with chronic health conditions or diagnoses. It identifies individuals with chronic diseases, assesses their health status, develops a program of care and collects data to evaluate the effectiveness of the process. It intervenes proactively with treatment and education so that the individual with a chronic disease can maintain optimal function with the most cost-effective and outcome-effective health care expenditure.

Primary Objectives of DM

o Encourage disease prevention and maintenance of good health Promote correct diagnosis and treatment planning Maximize clinical effectiveness of interventions Eliminate ineffective or unnecessary care and interventions Eliminate duplication of effort and activity Utilize only cost-effective diagnostics and requirements Maximize the efficiency of healthcare delivery while maintaining

appropriate standards of quality Continually improve outcomes of the care delivery process

Emphasizes an evidence-based approach

Requirements of a successful DM program Holistic/Team approach with healthcare professionals working

together in a cooperative and coordinated approach Understanding the course of the disease/practice guidelines Targeting patients likely to benefit from intervention Takes into consideration the total cost across the entire continuum

of care Appropriate information to the development & evaluation of “best

practice” for particular diseases Focusing on prevention and resolution Increasing patient compliance through education Providing full care continuity Audit must be integral part of medical practice Establishing integrated data management for outcome measurement Patient/Family involvement is critical

Skills & Tools in DM process

Skills/Tools Process

Medical database – informationon clinical and cost-effectivenessof all interventions

Disease

Review evidence

Clinical expertiseeg peer review groups, patient advocates

Define good practiceguidelines (evidence-based)

Clinical management tooleg patient follow-up reminders to aid collection of relevant data

Data collection

Outcomes database – store, retrieve, analyze outcomes

Data analysis

Clinical expertise Review outcomes data

OUTCOMES

Elements of Disease Management at the Mayo Clinic

Primary care practice guidelinesInformation SystemsContinuous quality managementResource management techniquesInformation managementSpecialty care managementHospital managementEmergency room managementPharmacy managementDiagnostic utilization managementCase managementPatient educationPrimary care teamsTriage system/telephone systemsBenefit design

Conceptual Model of the Healthcare Providers who may be involved in DM plan

Self-directed care

BasicPrimary Care

Extended PrimaryCare

Secondary& TertiaryCare

Long-TermCare

SocialServices

PublicHealth Personnel

-Family Practitioners-PracticeNurses-Pharmacists-Laboratory Service Providers

-CommunityNurses-Counselors-Physiotherapists-Occupationaltherapists

-SpecialistsCenters of excellence-Other serviceproviders

-Institutional Care-Nursing Home-Home Care

-Housing-Employment-Income Support

Developing a DM Plan

1. 1.     Identify an appropriate disease / case type and team

2. 2.     Determine current clinical practice

3. 3.     Perform an economic analysis in terms of disease burden

4. 4.     Identify key patient segments and target treatment groups

5. 5.      Identify critical (failure) points

6. 6.      Create a disease management plan (with key stakeholders)

7. Disseminate and reinforce the plan

Systems-Thinking Model: The Disease Management Process

1. Build a Shared Vision

2. Establish a Shared Reality

PLANNING 3. Understand & Share Key Benefits

4. Identify Barriers to Change

5. Develop Strategic Options

6. Identify Leverage Options

7. Determine how to measure results

DESIGN

IMPLEMENTATION

8. Learn & ContinuouslyImprove

Continuum of Care

Maintenance/RecoveryHealth Promotion

Disease Prevention

Disease Awareness/Symptom Recognition

Diagnosis

TherapyCompliance –Self Management

OutcomesMeasurement

Reintegration/Rehabilitation

Data Sources for Developing Disease Models

Data Sources

Epidemiology

Claims data

Expert panels

Economic and quality of life studies

Clinical trials for drugs, devices, diagnostics

Published literature

Primary market research

Disease models, disease maps,standards of care

Project impact of disease-specific process changes and utilization and cost control measurements

Basis for capitation and risk sharing

Validate

Core Components Processes of Outcomes Measurement

1. Define data requirements- Determine what sorts of outcomes need to be measured- Determine what measurement tools should be used

2. Obtain the data- Define data collection protocol- Implement data collection protocol

3. Manage the data- Create database- Enter data into database- Assure quality of data

4. Analyze the data- Analyze data quality and completeness- Determine method for scoring responses to outcome indicator- Perform risk adjustment- Perform outcome analysis

5. Report results- Prepare written summary of results- Present results to key customers

Disease Management in NHG

We have formed 8 teams that will focus on:

- Congestive Heart Failure / Acute Myocardial Infarction

- Asthma / COAD

- Stroke

- Diabetes Mellitus

- Hypertension / Hyperlipidaemia

- Specific cancers (eg breast, lung)

Development of clinical databases / disease registries

Primary healthcare enhanced care programmes

Disease Management – operational considerations

• Preliminary data – epidemiology and patient profiles, DRG data, financial data, etc

• Multidisciplinary workgroups to draft plans – develop shared care evidence-based protocols or pathways, case management practices and use of care coordination tools (eg telephone reminders, web-based interactive reminders)

• Focus on prevention and self management – establishment of a vascular disease risk factor prevention workgroup and using IT tools to promote patient adherence and self monitoring

• Standardising clinical pathways between institutions• Post discharge follow up and linkages with the community• Continuing care between the family physician, case manager and

hospital specialist

Disease Management – unresolved issues

• Funding for such programmes in an output-based, non-capitated environment

• Incentives for patients to do better for themselves

• Operational running costs for disease registries

• Incorporating quality of life measures into real and practical indicators which give providers a better understanding of the impact of interventions on health status

Critical Success Factors

• Select key clinician champions as leaders• Provide adequate resources and case managers to support the

programme• Appropriate funding incentives to be built into the system (eg

capitation in the USA)• Using information technology to harness clinical information

sharing and seamlessness at the back-end of care delivery• Team-based approach• Disease registries

Useful Contacts• Disease Management Association of

America (DMAA) – www.dmaa.org

• National Healthcare Group – www.nhg.com.sg

• HCFA website

• Managed care websites

Thank you

Jason_Cheah@nhg.com.sg

See you at Asia’s First Disease Management Conference

25-26 May 2001 Sheraton Towers Hotel, Singapore