Chronic Disease Management and Prevention in Canada

1
Chronic Disease Management and Prevention in
Canada

• North West LHIN
• Thunder Bay September 25, 2006
• Michael M. Rachlis MD MSc FRCPC
• www.michaelrachlis.com

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Outline

• Chronic diseases -- major impact and major
  problems for Ontarios health care system
• The Canadian Chronic Disease Model
• Assessing Ontarios readiness for CDM
• Canadian Chronic disease management excellence

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Chronic diseases have a major impact

• Chronic diseases account for 70 per cent of all
  deaths.
• Chronic diseases account for more than 60 per
  cent of health care costs.
• Chronic diseases account for one-third of the
  years of potential life lost before age
  sixty-five.

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Chronic diseases Common Risk Factors

• The Social Determinants of Health, especially
  work and life strain
• Unhealthy behaviours
• Smoking, other drugs
• Diet
• Physical Exercise

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Green et al Soc Sci Med 2003 57553-60
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Our health systems problems with chronic disease

• lt 30 of Canadians hypertensives have their blood
  pressure properly controlled
• 60 of diabetics have gone gt 1 yr without an eye
  exam or a check for proteinuria
• 60 of asthmatics are not properly controlled
• 20 of heart failure patients are readmitted lt
  60 days

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We could prevent most chronic diseases

• gt 80 of ischemic heart disease, lung cancer,
  chronic lung disease, and diabetes cases could be
  prevented with what we know
• This would free up over 6000 hospital beds across
  Canada

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Each System is Perfectly Designed to get the
Results it Achieves.We designed our health
system to manage acute illnesses, not manage
(much less prevent) chronic ones.
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http//www.improvingchroniccare.org
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Assessing Ontarios Readiness for CDMAssessment
of Chronic Illness Care (ACIC) Version
3.5Http//www.improvingchroniccare.org/ACIC20doc
s/ACIC_V3.5.doc
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Assessment of Chronic Illness Care

• Health care organization (6 items)
• Community linkages (3 items)
• Self management support (4 items)
• Decision support (4 items)
• Delivery system design (6 items)
• Clinical information systems (5 items)
• Creating supportive environments
• Strengthening community Action
• Building Healthy Public Policies

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Organization of the Health Care System

• Overall organizational leadership in CDM
• Organizational goals for CDM
• Improvement strategy for CDM
• Incentives and regulations for CDM
• Senior leadership
• Benefits

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Community Linkages

• Linking patients to outside resources
• Partnerships with community organizations
• Regional health plans

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Self-management support

• Assessment and documentation of self-management
  needs and activities
• Self-management support
• Addressing concerns of patients and families
• Effective behaviour change interventions and peer
  support

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Decision Support

• Evidence-based guidelines
• Involvement of specialists in improving primary
  care
• Provider education for CDM
• Informing patients about guidelines

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Delivery System design

• Practice team functioning
• Practice team leadership
• Appointment system
• Follow-up
• Planned visits for CDM
• Continuity of Care

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Clinical Information Systems

• Registry
• Reminders to providers
• Feedback
• Information about relevant subgroups of patients
  needing services
• Patient treatment plans

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Lack of Prevention

• No overall provincial health plan
• No health goals
• Unarticulated role for health services and public
  health for advancing population health
• Little coordination of social policy
• Dont get me started

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Ontario Chronic Disease Management Excellence

• Sault Ste. Marie Group Health Centre
• Congestive Heart Failure
• Dorval Family Health Team/Oakville CCAC
  partnership
• London InterCommunity Health Centre diabetes
  project
• The Sandy Lake Health and Diabetes Project

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London InterCommunity Health Centre diabetes
project

• Multiple entry points
• Multi-lingual
• Culturally appropriate care
• Community health workers
• International health professionals
• After hours
• Integrated with Primary care
• IT support

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CDM Requires System Change

• Re-orienting to patient self management
• Primary Health Care Reform
• Advanced Access
• Integration of primary health care with
• Secondary and tertiary care
• Public Health
• Home Care and Palliative care
• Mental Health
• Communications and IT support
• EHR, telephone, and internet

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Advanced Access Just in Time

• Cambridges Grandview Medical Centre and
  Torontos Rexdale and Lawrence Heights Community
  Health Centres have gone to same day servicing
• Saskatoon Community Clinic
• Penticton, Prince George
• All of these primary health care centres say that
  AA has increased their capacity to take on new
  patients and do CDM

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Integrating Specialty Care

• The Hamilton HSO Mental Health Program increased
  access for mental health patients by 1100 while
  decreasing referrals to the psychiatry
  outpatients clinic by 70.
• 145 MDs, 85 mental health counsellors, 17
  psychiatrists, 340,000 patients

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Getting Started on CDM in Ontario

• Home care partnerships with PHC
• especially for FHTs and CHCs
• Home care nursing for everyone gt 65 discharged
  from hospital with a serious chronic illness
• Patient self management training
• Learnings from London InterCommunity Health
  Centre diabetes project?

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Summary

• Chronic diseases have a major impact on our
  health care system
• Ontario health system isnt yet ready to manage
  or prevent chronic diseases
• Canadian versions of the Chronic Disease Model
  can provide guidance
• Canadian examples of excellence can provide
  inspiration

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Nows its time for perspiration!