Title: The Chronic Care Model as a vehicle for the development of disease management in Europe
1The Chronic Care Model as a vehicle for the
development of disease management in Europe
- Professor Cor Spreeuwenberg MD PhD
- Department Social Medicine
- Faculty of Health, Medicine Life Sciences
- Maastricht University
- INIC-Conference Gothenburg, 6th March 2008
2Content
- Chronic Diseases
- Some care approaches
- The Chronic Care Model
- US and Europe
- Conclusions
3Chronic diseases world wide
4Chronic Diseases
5Aims of chronic care
- prevention or delay of manifestation(s), where
possible - improved functioning of patients
- - reducing symptoms and complications
- - prolonging lifespan
- - improving quality of life
- - living independently
- - according own needs, demands and preferences
- effective, efficient and safe health care delivery
6Challenges of chronic care
- access
- prevention lifestyle
- integrated care
- effective and efficient care (delivery)
- co-morbidity and multi-morbidity
- tailoring to the needs of patients
- support of self-management
- organization on different levels
- care management support
- manpower
7Do we treat all aspects effectively?Results of
systematic approach of people with diabetes (N
15.269) at T0, T12, T24
8Lessons
- Supporting practitioners to improve their medical
skills seems to be more effective than paying
attention to behavioural interventions - However
- There are al lot of indications that most
practitioners are not skilled in applying
behavioural interventions - Behavioural interventions require different
approaches, time-sets and ways of patient
involvement
9Approaches to improve chronic care
- quality integrated care
- efficiency disease management
- outcomes Chronic Care Model
- Question do these approaches exclude each other?
10Integrated care- definition WHO (Gröne,
Garcia-Barbero), 2001- presented on
IJIC-conference in Strassbourg, 2002
- Integrated care is the bringing together of
- - inputs, delivery, management and
organization of services - - related to diagnosis, treatment, care,
rehabilitation and health promotion. - Integration is a means to improve services in
relation to access, user satisfaction and
efficiency
11Integrated care(Kodner/Spreeuwenberg, 2002)
- pragmatic definition a step in the process of
health systems and health care delivery becoming
more complete and comprehensive - contains a coherent set of methods and models on
funding, administrative, organizational, service
delivery and clinical levels - designed to create connectivity, alignment and
collaboration within and between the cure/ care
sectors - aims to enhance quality of life, consumer
satisfaction and system efficiency for patients
with complex, long-term problems cutting across
multiple services, providers and settings
12Disease Management- definition according to DMAA
(2004)
- a system (of)
- coordinated
- health care
- interventions and communications (for)
- populations with conditions (in which)
- patient self-care efforts (are)
- significant
13Disease managementbackground
- originally an American concept
- one disease or health problem
- feedback mechanism based on management
information - focus on efficiency more than on quality
- population orientation
- programmatic, systematic approach
- usually organized by a third party
142007 DMAA changed its name to Care Continuum
Alliance
- care continuum includes strategies such as
- - health and wellness promotion
- - disease management and
- - care coordination
- Care Continuum Alliance promotes the role of
population health improvement in - - raising the quality of care
- - improving health outcomes and
- - reducing preventable health care costs
- for people with - or at risk for developing
- chronic conditions
15The Chronic Care Model
16Chronic Care Model Aim
- To improve functional and clinical outcomes
- by relating processes on different levels
- - patient
- - practice team
- - organization responsible for the practice team
- - health care system
- - society
17Chronic Care Model central issue
- Creating a productive set of interactions
- between patient and practice team
18Informed, activated patient
- Application of principles of citizenship
- patient as owner of the disease
- understands principles of treatment
- able to make informed choices
- able to cope with relevant technology
- knows signs/symptoms of complications
- knows who to call for support
- active in preparing the next consultation
- This is an intention, but keep in mind that not
all - patient are capable to act on this way!
19Self-management
20 Support of Self-management -
information and education of patients -
21Prepared and pro-active practice team
- Competence in clinical care, attitude,
- organization and communication
- up-to-date knowledge and skills
- multi-disciplinary team
- accessible and transparent
- ready to support and to inform
- front- and back office
- co-operation issues
- delegation of tasks, if justifiable
- application modern technology
22A Network Information and Collaboration System
Personal Health Management
Patient
23Chronic Care Model related components or
conditions
- Community-level
- . resources and policies
- Health care delivery system-level
- . health care organization
- . delivery system design
- Practitioners/team-level
- . clinical information systems
- . decision support
- . self-management support
24Evidence based strategies with high success
factors
- Support of self-management
- - preventive messages (web etc.)
- - self care education
- Practice-level
- - disease registries to identify and track
people - - risk stratification models
- - services in community settings
- Substitution from physicians to nurses
25Europe its health systems and chronic care
approaches
- EU or related position
- health care national issue
- nationalized and mixed
- public/private systems
- various ways of organization
- various approaches to market mechanisms
- various ways of chronic care management
- cf Ellen Nolte
26Europe disease management and Chronic Care
Model general picture
- much support for CCM
- disease management initiatives independent from
nature health care system - disease management approaches compatible with
CCM-model - discussions within governments about their role
in implementing disease management - success also dependent of role of professionals
27Converging of American and European chronic care
approaches
- stratification based on complexity and patient
features - continuum of care
- connectivity of personal, practice and system
levels - prevention - and lifestyle influencing
- support of self-management
- availability and interconnectiveness of
information - quality control and improvement mechanisms
- improved functioning of the health care team
- information technology
28 Example StratificationUS-Ka
iser NL-Matador
Permanente
- Highly complex patients
Highly complex patients - - Intensive case management
- medical specialists - High risk patients
Moderate complex pts. - - Disease Management
- specialized nurses - Vast majority of pts
Non-complicated pts. - - Supported self-care
- practice nurses/GPs
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29From challenges to changes
- Implications
- - organisational
- - status and tasks of professionals
- - educational
- - financial
- Implications of change are significant, but
- the implications of not changing are even
more significant
30Chronic Care Model (its principles) as a vehicle
for disease management approach
- DM-approach
- - provoked by new health legislation (2006)
- intended for all chronic diseases with important
prevalence, starting with diabetes - new entities, often regional embedded, which
function as organizer and contractor - most entities formed by GPs
- insurers supposed to set the rules
- entities subcontract concrete caregivers
- data gathering bij a national institute (RIVM)
- starting problems (ICT)
- at this moment weak attention for CCM-aspects
31Opportunities to integrate disease management
approach with CCM
- development of care standards
- (how to use guidelines in daily practice)
- subjects
- . diabetes, COPD, cardiovascular risk
management - . to be developed heart failure, depression
etc. - . newly written care standards take CCM as
starting - point
- Conclusion
- CCM can function as a vehicle to introduce
- a adapted way of disease management
-
32Main messages
- The CCM can be successfully combined with a
diseases management approach - Care patterns must be based on complexity of
health problems and readiness of patients for
self-management - The nature of chronic diseases, together with the
upcoming shortage of staff, require a combined
effort of all involved to develop powerful
systems of self-management - Care standards based on CCM may function as a
vehicle to start with a European variant of
disease management - DM-organizations that mainly serve the interest
of regional practitioners, may hinder the
effectiveness and quality of chronic care in that
region -
- -gt I thank you very much