November 10, 2010

1. November 10, 2010 Innovative Care for Chronic Disease Prevention and Treatment in Low Resource Communities: An overview of the problem and solutions Ronald D. Deprez, PhD, MPHThe Center for Community and Public HealthCollege of Graduate Studies University of New England

2. 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

3. 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.

4. 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.

5. 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.

6. 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

7. 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

8. 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.

9. 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

10. Planned Care Model Community Health System Resources and Policies Health Care Organization ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Informed, Empowered Patient & Family Prepared, Proactive Practice Team Productive Interactions: -Patient Centered Care -Linked to Comm Resources -Timely and Efficient -Evidence-Based & Safe Improved Outcomes

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. Assessment for COPD • Target: 90% of patients will have evidence of being assessed for COPD by medical history, spirometry, and severity classification.

20. Treatment • Target: 90% of patients will have stepwise treatment plan that reflects severity of disease process (testing and treatment according to evidence-based guidelines) Patients Classified by Severity Stage 2 or > All patients

21. Rehab/Exercise • Target: 100% of patients will have referral to pulmonary rehab and continued documented exercise program

22. 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. Acute Exacerbation in Last Year Allpatients

23. 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.

24. 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.

25. TAMC Chronic Care Technology Project RESEARCH OBJECTIVES • Determine the effectiveness of the IHIcollaborative 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

26. 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

27. 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

28. Multiple Condition Chronic Care Improvement • Hyperlipidemia • Hypertension • Congestive Heart Failure • Diabetes • Chronic obstructive Pulmonary disease • Obesity • Major Depression

29. 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

30. Multiple Condition Chronic Care Improvement:Practice Change Process • Practice consensus on key disease targets for change • Decision support resource to generate patient visit flowsheets • Follow-up system for referrals to external resources

31. 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

32. Multiple Condition Chronic Care Improvement: Evaluation Measures • Use of Community Resources • Improvement in Linkages • Changes in Practice Behavior • Changes in Patient Outcomes • Changes in Patient and Provider satisfaction

33. 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.

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Practice Partner ModelCommunity level PSM Component • Provide PSM resources • Promote resource utilization • Link to patients and providers

43. Patient Self-Management Paradigm

44. Patient Self-Management Paradigm

45. Patient Self-Management Paradigm

47. Rapid Assessment Tools COMMUNITY LEVEL 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

48. Rapid Assessment Tools COMMUNITY LEVEL • 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

49. Rapid Assessment Tools PRACTICE LEVEL • 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

50. Rapid Assessment Tools PATIENT LEVEL—Quality Assessment • 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