DELIVERY SYSTEM REDESIGN:

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• DELIVERY SYSTEM REDESIGN
• PLANNED CARE FOLLOW-UP
• (Congestive Heart Failure)
• Art Macgregor
• Medical Lead
• Southern Vancouver Island
• HTF CDM Project
• Implementing the CCM in an Integrated Primary
  Care Network

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The first law of quality improvement

• Every system is perfectly designed to produce the
  results it gets (Shewart, Berwick)
• Our individual office is a health care delivery
  system it has been designed to produce the
  results which we are now getting.

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The second law of quality improvement

• The act of measurement itself improves
  performance (Macgregor and ?)
• Physicians do not like poor results and will
  change and improve performance when they
  understand the nature of the outcome of their
  work but to do so, they must have measured
  something.

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• The unexamined practice is a great opportunity
  (a great philosopher)
• How do you examine your practice?
• By having a registry
• By measuring something over time.

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• How does the BC health care system perform in the
  area of chronic disease management?
• Diabetes HbA1cd testing rate is 35-40
• Depression About 20 getting g-1 care
• Hypertension About 20 getting g-1 care
• CHF Under-prescribing of basic drugs
•  
• Since these results are relatively uniform across
  the province, could this be anything other than a
  systems problem?

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Delivery redesign Planned care and follow-up

• What are the issues for the family doctor?

1) Understanding that there is a problem 2)   
Believing that we can do better 3)    Believing
that with only a little more support we can do a
lot better 4)    Feeling that we are not going to
do much better without that extra support.
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Chronic Disease Management in the Family Doctors
Office

•  Lets presume that there will be, in the next
  year, some extra financial support for
  full-service practice.
•  Why you ask is all this needed?
•   Because while high quality care may be less
  expensive than poor quality care, it does take
  more time, more thought, and
• CHANGE IN DAILY ROUTINE it takes
• DELIVERY SYSTEM REDESIGN

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Modern Planned CHF Care 2003 Requires
 
1)  A new approach to diagnosis it can now be
made more precisely, more confidently and
therefore encourages more focused
planning 2)  Access to these new diagnostic
testing services 3)  A willingness to bang on the
table to get access to these services (the
argument is quality, precision, and
cost-effectiveness)
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4)  A plan to understand our total population of
patients -         how many are there with
CHF? -         how many on the appropriate
meds? -         If not, why not? -         What
specific inhibitions, barriers?   A chart review
is necessary to answer these questions - about
10-15 min. max./patient.   This hour or two may
be the most productive of the collaborative
because these are generic questions which go to
the heart of the problem of patient management in
the physicians office.
 
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Modern Planned CHF Care 2003 Requires
5) Knowledge of the new pharmacotherapies and
their ability to improve length and quality of
life (involves CME, academic detailing,
understanding on the part of Pharmacare) 6)  A
willingness to try to overcome fear of what we
imagine is a dangerous kind of therapy (and a
willingness to stop blaming the experts for
changing their minds so often)
 
7) Developing our skills in using multiple
medications for patients with multiple
co-morbidities (a diabetic with CHF could be
taking a dozen major drugs) 8)  Having patients
believe that polypharmacy is not automatically
bad or dangerous
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Modern Planned CHF Care 2003 Requires
 
9)   Planned care requires an interventionist
attitude which means that we cannot simply be
reactive to perceived patient need we need to
tell the patient up-front when to return
and/or To be very precise in instructions,
combined with nurturing patient self-management
skills and confidence   and/or To be using the
skills of home care nurses or chronic disease
management nurses and/or To be using email, or
telephone or other aids.
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Modern Planned CHF Care 2003 Requires
 

• 10)   Our part in planned care must include a
  pre-call/recall system
• 11) We need decision support tools which are
  easy to use thank God the new guide-line is
  only 10 pages long
• The best decision support for us would come in
  the form of a shared care program with
  cardiologists
• We need to be part of a team which in some way
  is felt to be collegial, supportive, and
  effective.

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