November 10, 2010November 10, 2010

Innovative Care for Chronic Disease Prevention and Treatment in Low Resource Communities:

An overview of the problem and solutionsAn overview of the problem and solutions

Ronald D. Deprez, PhD, MPHRonald D. Deprez, PhD, MPHThe Center for Community and Public HealthThe Center for Community and Public Health

College of Graduate StudiesCollege of Graduate StudiesUniversity of New EnglandUniversity of New England

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Agenda• Prevention and Chronic Disease Challenges

• What are the issues?• Are their solutions?

• CHPPR Example Projects and Results: Chronic Obstructive Pulmonary Disease (COPD) Chronic Care Technology Project Multiple Condition Care Improvement in Primary Care Healthcare Reform and Chronic Care (Vermont)

• Learning from the literature and field• Identifying System, Patient and Community Issues • Tools for Planning and Intervention• Ghana and Chronic Care Improvement• Next steps

Misunderstandings• Chronic diseases mainly affect high income countries.

– The reality is that four out of five chronic disease deaths are in low and middle income countries.

• Low and middle income countries should control infectious diseases before they tackle chronic diseases.

– In reality, low and middle income countries are experiencing a rapid upsurge in chronic disease, especially in urban settings. If left unchecked there will be a devastating future burden of chronic diseases in these countries.

• Even infectious diseases like Malaria act like chronic health conditions in populations as people become re-infected on a routine basis despite known remedies for prevention.

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Misunderstandings• Chronic diseases mainly affect rich people. In all but the lowest

resource countries of the world, poor people are much more likely than the wealthy to develop chronic diseases, and everywhere are more likely to die as a result.

– Moreover, chronic diseases cause substantial financial burden, and can push individuals and households into poverty.

• In countries of all income levels, middle-aged adults are especially vulnerable to chronic disease.

– However, people in low resource countries tend to develop disease at younger ages, suffer longer – often with preventable complications – and die sooner than those in high income countries.

• Levels of childhood overweight and obesity is a global problem. – About 22 million children aged under five years are overweight. In urban areas of China,

overweight and obesity among children aged two to six years increased substantially in the past 15 years.

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Misunderstandings• Certain chronic diseases, especially heart disease, are often viewed as

primarily affecting men. – The truth is that chronic diseases, including heart disease, affect women and men almost

equally.

• Individuals develop chronic disease as a result of unhealthy “lifestyles” and have no one to blame but themselves.

– The truth is that individual responsibility can have its full effect only where individuals have equitable access to a healthy lifestyle including food, physical activity and the environment.

• Governments only have a crucial role to play in improving the health and well-being of populations.

– In truth, both government and the private sector have a role to play. Governments have a role in providing special protection for vulnerable groups, especially children.

– Public private partnerships can play an important role in prevention and treatment of chronic health conditions. Supporting healthy choices, especially for those who could not otherwise afford them, is a societal responsibility.

5November 2010

Misunderstandings• Solutions for chronic disease prevention and control are too

expensive to be feasible for low and middle income countries. – In reality, a full range of chronic disease interventions are very cost-effective for

all regions of the world, including sub- Saharan Africa. Many solutions are also inexpensive to implement.

– Medications to prevent complications in people with heart disease, for example, are no longer covered by patent restrictions and could be produced for little more than one dollar a month.

– Patient education, self management, prevention can be implemented at low very costs to government

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The Global Burden of Chronic Disease

• Chronic diseases account for almost 60% of all deaths and 43% of the global burden of disease.

• By 2020 it is expected that deaths caused by chronic disease will rise to 73% of all deaths and 60% of the global burden of disease.

• 79% of deaths attributed to chronic diseases occur in developing countries.

*source: WHO Report 2002

*source: WHO Report 2002

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Africa’s Chronic Disease Burden

• Changing behavioral practices (sedentary lifestyles and diets high in saturated fat, salt and sugar) due to industrialization, urbanization, and increased food market globalization.

• Weak health systems that are unable to deal with the double burden of infectious and chronic diseases.

*source: de-Graft Aikins et al. Globalization and Health 2010.

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Chronic Disease in Ghana• By 2003 at least four conditions - stroke, hypertension, diabetes and cancer - had

become one of the top ten causes of death in at least each regional health facility in Ghana.

• Hypertension and obesity are major risk factors for chronic diseases. Childhood obesity has increased from 0.5% in 1988 to 1.9% in 1993/94.

• The Ghana Demographic and Health Surveys (DHS) demonstrate that prevalence of obesity or overweight among adult (non-pregnant) women across the country increased in ten years from 10% in 1993 to 25.3% in 2003.

• 2003 DHS data shows that there are more obese women (25.3%) than malnourished women (9%) in Ghana.

• A 2003 WHO sponsored national obesity survey that showed higher obesity rates in southern compared to northern regions. The report also showed higher obesity rates for women, married individuals, and older adults

*source: de-Graft Aikins. Ghana Med J. 2007 December; 41(4): 154–159

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Informed,EmpoweredPatient & Family

ProductiveProductiveInteractions:Interactions:

-Patient Centered Care-Patient Centered Care -Linked to Comm -Linked to Comm

ResourcesResources-Timely and Efficient-Timely and Efficient

-Evidence-Based & Safe-Evidence-Based & Safe

Prepared,ProactivePractice Team

Improved Outcomes

DeliveryDeliverySystemSystemDesignDesign

DecisionDecisionSupportSupport

ClinicalClinicalInformationInformation

SystemsSystems

Self-Self-Management Management

SupportSupport

Health SystemHealth SystemResources and Resources and PoliciesPolicies

Community Community

Health Care OrganizationHealth Care Organization

Planned Planned CareCare Model Model

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The Chronic Care ModelOrganization of Healthcare

• Senior leaders and staff must visibly support and promote the effort to improve care for chronic conditions

• Good assessment and planning is needed—gap analysis

• Resources must be allocated and barriers addressed

• Collaborative models must be integrated the into quality Improvement process

• Incentives are needed to obtain commitment and participation

• Culturally competent staff is needed

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The Chronic Care ModelDelivery System Design

• Optimize the Care Team

• Create a system to identify and remind providers

• Use planned visits in individual and group settings

• Use reminders and care-planning tools for patient visits (i.e. registries, flow sheets, etc.)

• Organize the follow-up process

• Use health advocates and community health worker programs for outreach

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The Chronic Care ModelDecision Support

• Embed evidence-based guidelines in the care process

• Establish linkages with key specialists to assure that primary care providers have access to expert support

• Provide skill-oriented interactive training programs for all staff in support of chronic illness improvement

• Educate patients about guidelines

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The Chronic Care ModelClinical Information Systems

• Establish a registry or some means of tracking patients

• Develop processes for use of the registry, including designating personnel to enter the data, assure data integrity, and maintain the registry

• Use the registry to provide feedback to care team and leaders

• Use database for pro-active patient management

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The Chronic Care ModelCommunity

• Establish linkages with organizations to develop support programs and policies

• Link to community resources for defrayed treatment (medication) costs, education, support and materials

• Encourage participation in community education classes and support groups

• Raise community awareness through networking, outreach and education

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The Chronic Care ModelSelf-Management

• Set and document self-management goals collaboratively with patients

• Understand and consider culture in treatment decisions

• Use self-management tools that are based on evidence of effectiveness

• Train providers on how to help patients with self-management goals

• Follow up and monitor self-management goals

• Use innovative techniques (group visits) to support self-management

• Use community resources to achieve self-management goals

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Centers for Medicare and Medicaid ServicesThe Quality Improvement Organization

Physician Office Component • Measure and report performance

• Primary care offices measure performance to identify opportunities for improvement and to track progress. Measures are based on clinical outcomes or evidence-based practices, systems and process implementation, patient experience, staff experience, and cost.

• Adopt Health Information Technology• Integrating health information technology into practices greatly enhances

quality, safety and performance. It gives providers the power to measure their performance for continuous improvement.

• Redesign Processes• Redesigning the system of care in practices improves patient and provider

satisfaction and ensures better care by implementing changes that enhance reliability and safety while minimizing waste and inefficiency.

• Transform Organizational Culture• Transforming practice office culture is critical to clinical quality, patient self-

management, care coordination, and safety as patients navigate the complex healthcare system.

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COPD Collaborative Project

• Twenty five practices serving several rural communities.

• Global Obstructive Lung Disease (GOLD) guidelines.

• IHI type change Collaborative.• Emphasis on practice change, patient

self management and use of community resources

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Assessment for COPD• Target: 90% of patients will have evidence of being

assessed for COPD by medical history, spirometry, and severity classification.

0%

20%

40%

60%

80%

100%

Target DetailedMedicalHistory

SpirometryEver Taken

SpirometryLast Visit

SeverityClassification

(0-4)

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Treatment• Target: 90% of patients will have stepwise treatment plan that

reflects severity of disease process (testing and treatment according to evidence-based guidelines)

All patientsPatients Classified bySeverity Stage 2 or >

0%

20%

40%

60%

80%

100%

Target At Least OneTest Conducted

Receivingmedication

0%

20%

40%

60%

80%

100%

Target Testing (for stage 2 orhigher)

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Rehab/Exercise• Target: 100% of patients will have referral to

pulmonary rehab and continued documented exercise program

0%

20%

40%

60%

80%

100%

Target Referral topulmonary

rehab

Discussion ofexercise

program orregime

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Self-management• Target: 90% of all patients will have documented self

management goals and patient education for each appointment with reassessment of goals after acute exacerbation.

All patientsAcute Exacerbation in Last

Year

0%

20%

40%

60%

80%

100%

Target Documentedgoals

Educationalmaterialsreceived

0%

20%

40%

60%

80%

100%

Target Follow-upappointmentscheduled

Re-assessmentof goals

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Chronic Care Technology Project

• 3- Year $1.2 m HIT implementation grant funded by the Agency for Healthcare Research and Quality (AHRQ)

• Objectives are to see if IHI change process can be used to improve technology; and if improves the care for chronically ill patients.

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TAMC Chronic Care Technology Project

GOALS

• Improve regional-based, evidence-driven chronic disease patient care through the use of health information technology

• Adopt technology solutions that will improve quality and efficiency of patient information transfer among– primary care physicians– pharmacies– home health agencies– nursing homes– hospitals

• Adopt work processes to improve patient care coordination and availability of patient data among healthcare organizations.

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TAMC Chronic Care Technology Project

RESEARCH OBJECTIVES

• Determine the effectiveness of the IHI collaborative model in adopting and implementing technology changes within and between healthcare organizations.

• Determine if technology changes improve the quality and efficiency of information transfer

—timeliness, accuracy, security, usefulness, and cost.

• Determine if an improved patient data transfer system (technology changes) improves patient care management and provider satisfaction

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Technology Project –Preliminary Findings

• Activities/Support– Most organizations had difficulty implementing initial changes – Some organizations seemed to be lacking appropriate and

timely IT support

• Barriers– Finding time to devote to this project– Getting technology set up and working; training staff how to

use technology– Costs of technology is a barrier– Some of the partners were not able to or interested in

receiving information from them

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Multiple Condition Chronic Care Improvement• A two-year project funded by the Physicians’ Foundation for

Health Systems Excellence (PFHSE)

• Goal: Enable rural PCP’s to develop sustainable quality of care improvements for patients w/multiple chronic health conditions (3 or more)

• Interventions at both the practice and community levels

• Project to address: barriers to change in PCP’s; patient barriers in access to care and effective self-mgmt; and identify ways to link community resources and PCP’s

• Uses a Consensus building model of improvement

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Multiple Condition Chronic Care Improvement

• Hyperlipidemia• Hypertension• Congestive Heart Failure• Diabetes• Chronic obstructive Pulmonary disease• Obesity• Major Depression

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Multiple Condition Chronic Care Improvement

• Focus on improved patient care and patient health outcomes through:– Practice process improvements

• Use of patient flow sheets w/targets• Use of patient self management resources

– Patient goal setting and action plans– Community resource information system

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• Practice consensus on key disease targets for change

• Decision support resource to generate patient visit flowsheets

• Follow-up system for referrals to external resources

Multiple Condition Chronic Care Improvement:Practice Change Process

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Multiple Condition Chronic Care Improvement :Community Intervention

• Web based information system • Local/regional resource directory for the care of chronic

conditions• External information resource links • Community events—screenings, health fairs, etc.• Self administered risk profiling program

• Health Services Linkages • Providers to providers• Community organization/employers • Community members/patients and families

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1. Use of Community Resources

2. Improvement in Linkages

3. Changes in Practice Behavior

4. Changes in Patient Outcomes

5. Changes in Patient and Provider satisfaction

Multiple Condition Chronic Care Improvement: Evaluation Measures

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Vermont Blue Print for Health

Vision• Vermont will have a statewide system of care that

improves the lives of individuals with and at risk for chronic conditions.

• To achieve its vision, the Blueprint will:• Utilize the Chronic Care Model as the framework for system

change;

• Utilize a public-private partnership to facilitate and assure sustainability of the new system of care;

• Facilitate alignment of Blueprint priorities and projects with other statewide health care reform initiatives.

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Vermont Blue Print for Health

Goals:• Lower prevalence of chronic conditions

• Slow—then reverse the rise in obesity

• Better Health Outcomes• Improved clinical status• Improved quality of life

• Moderation in costs• Lower per capita costs• Slower rise in total costs

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Lessons Learned

• Success is directly related to Provider Leadership, but Practice Management and staff are also key

• Primary Care Providers must have support to implement sustainable practice change

• Time• Compensation• Resources

– Funds– Expertise

» Change process support» Billing and Reimbursement» IT

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Lessons Learned

• Sustainability has to be a value proposition• Improving Patient Quality of Life and Clinical

Outcomes

• Improving financial rewards

• Improving productivity based on system change and practice team responsibilities

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Lessons Learned• We know a lot about best practice chronic disease care

• We have good tools for population need assessments

• We have some tools for practice and quality care assessment/planning

• We have several proven practice improvement processes – IHI, office Microsystems (Dartmouth) are examples

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Lessons Learned

• Practice change is difficult and takes a long time

• Technology changes can be very challenging

• Single disease initiatives may not carry over to other diseases

• Sustaining practice and system change takes funding that may not be available

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Lessons Learned• We need better rapid assessment tools

• For understanding patient barriers

• We need to do a better job at integrating patient barriers information into practice changes

• We have not linked practice and community resources for patient care very well

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The Practice Partner ModelPractice level PSM Component

• Educate/empower patients on self care

• Link patients to appropriate community services

• Assist patients to overcome barriers to self care

• Aid patients in specific goal setting/action plans and follow-up

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The Practice Partner ModelPatient/Family level PSM Component

• Empower patients to communicate effectively with providers on self care/treatment issues

• Get/stay informed about health conditions, treatment plan, and steps required to comply

• Understand and adhere to medication instructions

• Set specific goals and action steps

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Practice Partner ModelCommunity level PSM Component

• Provide PSM resources

• Promote resource utilization

• Link to patients and providers

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Patient Self-Management Paradigm

Practice level PSM component

Enable patients to do self care

Facilitate use of community services

Assist pts to overcome barriers

Aid pts in goal setting

Provide Pts access to SM materials

Create/monitor action plan with patientsInvolve patients in

treatment planPromote group visits,

patient support groupsLink patients to

community providers/develop feedback

systemStay connected to

patients between visitsPractice evidence based medicine

Patient centered practice:

Improve use of evidence based

medicine Improved

communication w; pats/community providers

Improved patient health status/self-efficacy Improved patient/

provider satisfaction

Key Stakeholders OutcomesFunctions Tasks

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Patient Self-Management Paradigm

Patient/family level PSM component

Actively address care Get/stay informed and

motivatedLink to support systems

and providersAdhere to medication

instructionsSet specific goals

Understand your symptoms/conditions/

treatment plansCommunicate regularly

w/providers on treatment issue and

barriersConnect to support

networksEstablish health goals and actions to achieve in specific time period

Develop/use medication reminders

Patient directed self management:

Improved self efficacy to deal w/chronic

conditionsIncreased personal

responsibilityImproved care plan

adherence Improved health status Improved satisfaction

w/care system

Key Stakeholders OutcomesFunctions Tasks

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Patient Self-Management Paradigm

Community level PSM component

(includes gov, providers, employers, coalitions)

Provide PSM resourcesPromote resource

utilizationLink to patients and

providers

Develop/promote support groups

Identify/reduce access barriers

Communicate with population and

providers on resources available

Identify/Develop/Maintain community

based servicesPromote health

improvement policies

Patient centered care system:

Improved community based resources

Improved communication

between providers and patients

Better access to careHealthier population

Key Stakeholders OutcomesFunctions Tasks

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Rapid Assessment Tools

Community Health Needs Assessment– Disease prevalence by geography/populations– Health system environment and resource issues– Chronic Care plan

Health Services Availability and Linkages – Community level services by condition – Measure linkages to medical care – Prioritize areas for improvement

COMMUNITY LEVEL

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Rapid Assessment Tools

• Health Policy Impact Assessment– Local/state/national policies that impact

chronic care prevalence and management • Environmental• Food• Tobacco • Taxation

– Identify model policies – Barriers and resources

COMMUNITY LEVEL

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Rapid Assessment Tools

• Practice infrastructure tool– Identification of gaps in components of quality

• Health improvement Team• Decision Support Systems• Use of Evidence Based Guidelines • Patient Self Management Tools

– Prioritize systems/activities for improvement– Technology and practice improvement

processes

PRACTICE LEVEL

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Rapid Assessment Tools

• Patient level data– Quality of Care Practices—workflow

assessment– Use of best practices/clinical guidelines—

patient chart review– Prioritize target indicators for improvement– Practice improvement strategies to get there – Workflow issues to overcome

PATIENT LEVEL—Quality Assessment

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Rapid Assessment Tools

• Patient Barriers Assessment– Treatment Barriers:

• Insurance / Transportation / Language / Culture / Provider communication

– Self Management barriers• Self management knowledge, skills and

attitudes– Literacy/Family Support

• Patient adherence strategies

PATIENT LEVEL

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Chronic Care Rapid Assessment ToolsMain Principles

• Speed – the methods are intended to provide relevant information quickly, upon which decisions about health care interventions can be made;

• Use of multiple data sources – different methods are used to access different sources of data to get a balanced overview;

• Pragmatism – the methods should provide adequate information, without necessarily being ‘scientifically perfect’. Triangulation, or cross-checking between different sources of data is used to establish the validity and reliability of the data collected;

• Cost-effectiveness – the focus is on research instruments that provide information cheaply, and for the most part are not labor and time intensive. Where possible, use is made of existing data.

- excerpted from the Rapid Assessment Protocol by Louise Hayes, Richard Edwards, Philip Setel, and Nigel Unwin

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Chronic Care Rapid Assessment ToolsPractice Infrastructure Assessment Tool

• Identify gaps in pre-requisite components for improving quality care

• Prioritize target systems and activities for improvement

• Enable the design of technology and practice improvements

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Chronic Care Rapid Assessment ToolsQuality of Patient Care Assessment Tool

• Assess use of best practice guidelines by disease/condition

• Prioritize target indicators to improve

• Identify practice improvement strategies to focus on

• Identify project design issues to overcome

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Chronic Care Rapid Assessment ToolsCommunity-Based Health Services Linkage Tool

• Assess the extent to which community health care needs are met by existing resources

• Identify additional resources needed

• Identify how existing resources can be better linked to primary care and patients for prevention, diagnosis and treatment

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Chronic Care Rapid Assessment ToolsPatient Barriers to Treatment and Self Management

• Identify patient care access issues

• Identify self management knowledge, skills and attitudes

• Prioritize patient adherence targets and strategies

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Chronic Care Improvement in Al Gharbia

• Al Gharbia Region (Egypt) Chronic Care Health System Improvement Planning– Need:

• Chronic disease in Egypt accounts for up to 78% of all deaths • Risk factors are high—smoking, obesity, • Prevalence of HBP, diabetes and High Cholesterol thought to

be rising • MOHP has recognized the need

– Insufficient regional level data

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Chronic Care Improvement in Al Gharbia

Planning Improvement—Steps• Characterize the range of chronic conditions in the governate

• Assess resource capacity in the community and health sector (prevention, detection, treatment and self management of patients)

• Identify priority chronic conditions, gaps in services and key obstacles to providing high quality chronic care services

• Develop strategies for addressing service gaps and detailed plans for improving quality of chronic care services and reducing patient barriers to care.

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NEXT STEPS