Canadian Heart Health Strategy and Action Plan CHHSAP The Need for System Change in Cardiovascular C

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Canadian Heart Health Strategy and Action Plan
(CHHS-AP) The Need for System Change in
Cardiovascular Care Potential Role for the
Chronic Disease Management ModelQuébec
CityOctober, 2007
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Outline

• Introduction Dr. Eldon Smith
• Principles of Chronic Disease Management Dr.
  Richard Lewanczuk
• CDM as applied to congenital heart disease Dr.
  Richard Lewanczuk
• Treating the right patient in the right place at
  the right time Lessons learned from an AF clinic
  - Dr. Anne Gillis
• CDM as applied to cardiac rehabilitation Dr.
  Neville Suskin
• Discussion

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Why is chronic disease management (CDM) important
?Richard Lewanczuk MD, PhDUniversity of
Alberta
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Conflict of interest statement

• Dr. Lewanczuk has participated in advisory boards
  and/or received honoraria from Abbott, Bayer,
  Boehringer-Ingelheim, Glaxo, Merck, Novartis,
  Pfizer

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Why Should Canada Be Interested In Chronic
Disease ?

• 60-100 of adults have a chronic disease
• 60 of hospitalizations due to chronic disease
• 2/3 of medical admissions via emergency due to
  exacerbation of chronic disease
• 80 of family doctor visits chronic disease
  related
• 60-80 medical costs related to chronic disease
• Largest driver of pharmaceutical costs

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increase in Medicare costs 1987-2002 for
chronic diseases
Thorpe and Howard, Health Affairs 25w378, 2006
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Prevalence of chronic diseases Medicare 1987 to
2002
Thorpe and Howard, Health Affairs 25w378, 2006
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Current State of Chronic Disease Why?

• System designed around acute, episodic care
• Urgency trumps severity
• Incentives are misaligned
• Reactive decision-making
• A system that is highly fragmented
• Patients are lost in transition
• Information is not shared
• Evidence Based Medicine is not at the point of
  care
• Patients not enabled to manage their chronic
  illness

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Challenges in real life
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Prevalence of 2 or more chronic diseases

• Thorpe and Howard, Health Affairs 25w378, 2006
• Daveluy et al, Institute de la statistique du
  Quebec, 2001
• Fortin et al, Ann Fam Med 3223, 2005

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The Challenge In Canada
22 of Canadians 18-70 years of age have
hypertension 50 of Canadians gt65 years of age
have hypertension
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of day required for CDM based on published
guidelines
Lewanczuk, adapted from Ostbye et al Ann Fam Med
2005 3209 based on average family physician
work day
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Competing demands or clinical inertia the case
of elevated glycosylated hemoglobinParchman et
al, Ann Fam Med 5196, 2007

• Factors which decrease the likelihood of
  medication change in response to elevated HbA1c
• more long term medications
• number of patient concerns
• number of topics discussed by physician
• shorter encounter
• HbA1c closer to normal

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Figure 3
Age Gap Quintiles
The Check Up Study
Grover et al, in press, Arch Internal Med
(courtesy of Dr. S. Grover)
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Patient-identified barriers to (diabetes) control

• 55.5 psychological (priorities, motivation,
  self-efficacy, competing demands, emotional)
• 25.7 external physical (access time,
  appointments, mobility, location monetary)
• 24.8 psychosocial
• 23.9 internal physical (other conditions,
  side-effects)
• 15.3 educational

Simmons et al, Diabetes Care 30490, 2007
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What were the 2 patient-identified barriers to
diabetes control ?

• the regimen is too complicated
• I have more than one disease

Simmons et al, Diabetes Care 30490, 2007
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Determinants of treatment adherence

• demographics
• biological markers
• health history
• time with condition
• symptoms (or lack of)
• acceptance of condition
• perceived benefit
• perceived risk
• co-morbidities
• complexity of regimen
• stage of change
• physician-patient relationship
• pharmacist-patient relationship
• prior treatments/attempts

• expectations/beliefs
• habits
• social factors
• psychological state
• goals
• triggers
• social support
• side effects
• cost
• refill convenience
• lifestyle disruption
• motivation
• self-confidence

• knowledge

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Problems created by CPGs

• ignore complexity of multiple diseases and
  priorities in that regard (e.g. lower the LDL or
  lower the BP?)
• recommendations are based on the single disease,
  not taking into account other diseases (e.g.
  weight bearing exercise in osteoprosis vs not in
  diabetic neuropathy)
• ignore life expectancy and quality of life
• no consideration of burden of care on patient or
  family
• no consideration on finances

from Boyd et al, JAMA 294716, 2005
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Problems created by CPGs

• no balancing of short vs long term goals
• no consideration of patient preferences
• no disease-disease interactions considered (e.g.
  avoid hypotension, hypoglycemia in osteoporosis
• CPGs not designed for quality assessment
  transforming into performance standards is
  problematic
• single disease silos perpetuated
• patient perspective not considered (e.g. quality
  of life)

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QUESTION

• Is this assessment of Clinical Practice
  Guidelines Fair ?

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Principles of CDM
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The Historical Approach To Chronic Disease
Management

• Patient develops a chronic disease
• Family doctor doesnt have time or resources to
  deal with the surrounding complex issues (e.g.
  diabetes or heart failure)
• And
• No systematic follow-up, patients come back with
  acute problems
• Or
• Specialists establish chronic disease clinics
  and encourage family doctors to send their
  patients there

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Impact Of Specialty Disease-Specific Clinics

• Potentially excellent care delivered to select
  few patients
• Lack of care coordination 75 of CDM patients
  have more than 1 chronic disease
• Confusion about responsibilities
• Specialist resources are limited
• What about the rest (two-tiered medicine) ?

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Principles of Chronic Disease Management

• responsibility for populations
• identify patients (case finding)
• stratify by risk and provide care in least
  intensive setting
• treatment in the community before it impacts on
  more complex acute care services
• primary care provider runs the show
• provides care, coordinates care, is responsible

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Principles of Chronic Disease Management

• involve patients in their own care (goal setting)
• inter-disciplinary teams
• patient support in disease management with
  ongoing follow-up and education
• delegated care right provider, right time, right
  place
• the system supports the primary care provider
  patient relationship
• evidence-based medicine

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Principles of Chronic Disease Management

• specialists act as advisors, mentors, resource
• information systems allow access and transfer of
  key patient data
• integration of care across organizational
  boundaries
• effective organization of care/service delivery
  to improve health outcomes
• performance measurement tools to track quality of
  care indicators

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CDM Levels of Care

• Primary Care Physicians and teams are supported
  to provide the best care to the most people
• Specialty clinics provide care management to
  complex cases
• Case management is reserved for the most
  challenging situations

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QUESTION

• Are these principles realistic ?
• Is stratified care realistic ?

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The Chronic Care Model

• Developed by Dr. Ed Wagner, MD, MPH, FACP and
  others Based on work by Group Healthcare
  Cooperative in Puget Sound, WA
• Multidimensional solution to CDM
• In use at more than 500 U.S. health care
  organizations endorsed by the WHO
• Proven to improve outcomes and reduce costs

www.improvingchroniccare.org
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The Chronic Care Model
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The Chronic Care Model

• Community Resources and Policies
• Linkages to community-based resources/ partners
• Policies to promote/ prevention of CDM

• Health Care Organization
• Leadership, culture and mechanism to promote
  safe, high quality care.
• Effective relationships with other stakeholders
• Clear structures and goals

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The Chronic Care Model

• Clinical Information Systems
• Enable sharing of information electronically
• Provide disease registries for planning
  individual care and
• conducting population-based care
• Monitor performance and track outcomes

• Self Management Support
• Emphasize patient empowerment
• Help patients and
• families acquire self management skills and
  confidence to manage their disease
• Multiple patient education strategies

• Decision Support
• Evidenced based care
• Reminders, alerts, protocols
• Continuing education for providers

• Delivery System Design
• Organized, planned proactive care
• Standardized business and clinical processes
• Defined roles and
• responsibilities
• Primary care infrastructure

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Patient Self-Management Approach

• Patients/clients are
• Informed about their disease
• Confident in self-management skills
• Empowered to make decisions
• Encouraged to set goals measure progress
• Taught how when to initiate contact with the
  health system
• Supported through successes setbacks
• Followed regularly and consistently

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The Role Of The Specialist?
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Traditional Role Of The Specialist
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New Role Of The Specialist
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The Right Provider At The Right Place At The
Right Time

• This looks like a job for a Specialist

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Who Should The Specialist See?

• Complex patients
• Atypical patients
• Uncontrolled patients (after exclusion of
  patient-factors best dealt with at a primary care
  level e.g. depression)
• Patients where the family physician needs
  guidance
• Teaching patients
• Other
• (NOT non-adherent patients)

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What Does This Mean To The Specialist?

• Caring for more complex patients
• Co-responsible for a population of patients
• Partnership with the Primary Care Physician
• Reaffirm the role of the primary physician
• Mentor / Coach
• More virtual consultations
• More utilization of clinical information
  technologies
• Working within a multidisciplinary environment
• Remuneration issues

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What does this mean for the patient ?

• Health Care not Illness Care
• Personal responsibility
• Strong emphasis on staying healthy with support
  to do this !
• The health care team works with the patient to be
  pro-active in maintaining health (e.g. assesses
  risk for conditions, keeps up to date with
  routine interventions such as immunization, Pap
  smears, blood pressure checks)

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What does this mean for the patient (contd)?

• Increased community supports
• Increased access to information (e.g. patient
  portal)
• Care coordinated and managed by primary care team
  
• Less reliance on just physicians, increased
  access to other health care professionals
• Specialists see more complicated patients
• Ability to access appropriate care, at right
  place, right time (i.e. shorter waiting lists or
  no waiting lists)
• All health care needs are addressed, not just a
  single problem

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TWG 6
primary care
case management
self management
patient
risk stratification high medium
low

• generic services
• behavior change
• exercise
• community
• self-management

• specialty services
• HF clinic
• rehab
• palliative
• geriatric
• home care

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Electronic Medical Records and Registries
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Patient Profile Viewer
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Dashboard
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Dashboard Trend
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Dashboard Drilldown Flow
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Steps in CDM

• Screen / identify patients with condition
• Register patients with condition
• Determine responsibilities of primary care team
  versus specialty services
• Develop care maps, protocols (decision support
  evidence-based)
• Ensure patients are on care maps and develop
  means to track patients, mechanisms for alerts
  and updates to patient plan
• Track markers disease specific, intermediate
  endpoint, hard endpoint
• Allow for patient self-management

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CDM as applied to pentology of Fallot

• Screen / identify patients with condition
• Register patients with condition
• Determine responsibilities of primary care team
  (immunization, usual childhood conditions) versus
  specialty services (imaging, cath, medications,
  determination of surgery, timing, surgery,
  post-op follow-up)
• Develop care maps, protocols

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CDM as applied to pentology of Fallot

• 5. Ensure patients are on care maps and
  develop means to track patients, mechanisms for
  alerts (update evidence and best practice)
• 6. Track markers disease specific,
  intermediate endpoint, hard endpoint
• 7. Community resources (Pentology of Fallot
  support network)
• 8. Patient self-management (knows when to
  rest, knows about dental precautions, need for
  immunizations, accesses patient portal results,
  information on condition)

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The Chronic Care Model

• Clinical Information Systems
• Enable sharing of information electronically
• Provide disease registries for planning
  individual care and
• conducting population-based care
• Monitor performance and track outcomes

• Self Management Support
• Emphasize patient empowerment
• Help patients and
• families acquire self management skills and
  confidence to manage their disease
• Multiple patient education strategies

• Decision Support
• Evidenced based care
• Reminders, alerts, protocols
• Continuing education for providers

• Delivery System Design
• Organized, planned proactive care
• Standardized business and clinical processes
• Defined roles and
• responsibilities
• Primary care infrastructure

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CHHS-AP

• Contact
• 613. 569.4361 ext 254
• info_at_chhs-scsc.ca
• www.chhs-scsc.ca

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Food for thought

• are patients who attend heart function or other
  chronic disease specialty clinics (e.g. risk
  reduction) selected for success?
• does a heart function clinic have better outcomes
  that a properly resourced and supported family
  healthcare team?

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Food for Thought

• what role currently carried out by specialty
  clinics, could be carried out by family care
  teams ?
• what work currently done by specialists or family
  doctors, could be done by other health care
  professionals ?
• what would need to be in place to shift
  cardiovascular care into a chronic disease model
  ?

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Outside the Box Questions

• Does every patient with heart failure need to be
  evaluated in a heart function clinic?
• Who should be seen in a heart function clinic,
  who shouldnt?
• Pros and cons of yearly follow-up in a heart
  function clinic

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Discussion/Questions?