Preventing and Managing Chronic Conditions

1. Preventing and Managing Chronic Conditions Chronic Disease & Health Management Reconfiguring Health Systems, 2nd edition Bucharest, Romania September 22, 2010

2. Canada • Population - 31 million people; 10 provinces & 3 territories • Official languages – English & French • Health Care – publicly funded by Provinces and Federal government • Health Care Providers employed by government except Physicians - fee for service

3. Where is Calgary ?

4. Rocky Mountains 4

5. Oil 5

6. Cowboys 6

7. Winter 7

8. Hockey 8

9. Chronic Conditions Preventing and improving care for the chronically ill is one of the most pressing health needs of our time • Chronic conditions are steadily becoming the leading cause of disability and health care costs around the world 9

10. Chronic Conditions • Populations are aging and patients are living with one or more chronic conditions for decades • Latest Canadian figures suggest 6 out of 10 people have a chronic disease 10

11. How can we minimize the impact of the tsunami that is about to hit us? 11

12. Health Care System Redesign • Our health system is designed to manage acute illnesses, not manage (much less prevent) chronic ones ‘Each system is perfectly designed to get the results it achieves ‘ W. Edwards Deming

13. Chronic Illness in Canada “ Surveys across a variety of diseases including high blood pressure, diabetes, coronary artery disease, asthma and congestive heart failure have shown that 40 to 80 percent of patients are inadequately treated.”

14. Expectation ≠ Experience

15. What Must be Done? To evolve from acute focused ‘find it and fix it’ health care system towards one that is proactive, provides comprehensive and coordinated care and is designed to meet the long term needs of patients. ‘ Trying harder will not work. Current health systems cannot do the job. Changing care systems will ’. US Institute of Medicine, 2001

16. Chronic Care Model www.improvingchroniccare.org HEALTH SYSTEM COMMUNITY Health Care Organizations Self-Management Support ClinicalInformationSystem Resources & Policies Delivery System Design Decision Support Prepared, Proactive Practice Team Informed, Empowered Patient Productive Interactions Improved Outcomes

17. Expanded Chronic Care Model (Canada) www.health.gov.bc.ca/cdm/cdminbc/chonic_care_model.html

18. Two Key Strategies to improve Chronic Care • Across the country strategies being undertaken to • Strengthen primary care • Increase focus on prevention • Mix of service delivery models asProvinces and Territories are free to organize and deliver health services as long as adhere to Canada Health Act.

19. Strengthening Primary Care • Well established that stronger primary care leads to better health outcomes • Majority of chronic diseases can be managed at the primary care level with appropriate support • An interdisciplinary team to support the diverse needs of patients • Involvement of specialists to provide decision support, education and episodic medical care

20. Strengthening Primary Care • Over last 5 years Primary Care Networks being formed • Groups of family physicians team up to work together to provide core services to patients eg chronic care • Networks receive a per capita payment to facilitate optimal care eg hiring interdisciplinary teams to support chronic disease management

21. Strengthening Primary Care • Increased emphasis on person, not disease • Greater attention to health promotion & disease prevention • Interdisciplinary team of providers • Better coordination of patient’s care • Less variation in care that patients receive • In Alberta, over 60% of family physicians now in Primary Care Networks

22. Care Plans • Care planning also introduced to encourage interdisciplinary care and support patients to be more involved in care • Care plans completed by primary care team and patient • Outline the patient’s goals, upcoming interventions and the role of all the providers involved in care • Flinders Care Plan methodology is an approach with evidence that it improves clinical outcomes, reduce service utilization, improves patient/provider satisfaction) • www.som.flinders.edu.au/FUSA/CCTU/self_management.htm

23. Canadian MD’s don’t use Care Plans 100% Percent giving written plan 75% 50% Mean Rating (0 – 100%) 25% 0% AUSTRALIA GERMANY CANADA NETHERLANDS NEW ZEALAND UNITED STATES UNITED KINGDOM Source: Rachlis 2008

24. New Fee Code for family physicians – Complex Care Plan – launched April 1, 2009 in Alberta Source: Calgary Herald, March 16, 2009

25. Care Plans • Take focus away from disease to patient as a whole • Address all chronic conditions and take into account the person’s psychosocial issues • Are motivational for patients • Facilitate communication between patient and providers • Specify role of multiple providers • Assess and support patient’s self-management skills

26. Why is patient self-management important?

27. Six Principles of Self-Management • Knowledge of condition and treatment • Understanding and taking of medication • Sharing in decision-making • Keeping appointments

28. Six Principles of Self-Management (cont’d) • Monitoring and managing symptoms • Managing impact of condition on physical activity, emotions and social life • Stanford Chronic Disease Self-Management Program, developed by Dr. Kate Lorig, Stanford University, in early 1980’s • http://patienteducation.stanford.edu

29. Chronic Disease Prevention • Chronic Diseases are highly preventable • As much as 80% of heart disease, stroke and diabetes, and up to 30% of cancers could be prevented by changing modifiable risk factors such as tobacco use, unhealthy diet, lack of physical activity, and excessive alcohol use.

31. Comprehensive Prevention Strategy • Prevention offers the most cost-effective long term strategy for chronic disease and cancer control. • A comprehensive prevention strategy is needed that blends • a risk-factor reduction approach in the broad population • with a focus on high-risk populations (World Health Organization, 2008).

32. Preventing Chronic Disease - Upstream Approach

33. Managing Chronic Disease - Downstream Approach

34. Broad Population Approach • Low resource community based initiatives that target general lifestyles and transforming social and physical environments • Based on the successful North Karelia, Finland initiative to prevent chronic disease in the 1970s • Engage communities in identifying their own needs and priorities and programs with support and consultation and small grants from health system • Walk21 – formed in 1999 to help create healthy, efficient and sustainable walking communities throughout the world. • provides a framework to assist community leaders refocus their existing policies, activities and relationships to create a culture where people choose to walk. http://www.walk21.comhttp://www.canadawalks.ca/

35. Programs for High Risk Population • Chronic Disease Action Plans • Provide a way for practitioners to help individuals to make the lifestyle changes necessary to reduce their risks by maximizing their self-management potential • Identify and assess the key modifiable risk factors of smoking, nutrition, alcohol, physical activity and stress • www.som.flinders.edu.au/FUSA/CCTU/self_management.htm

36. Process • Tools assess: • Knowledge of risk factor(s) • Knowledge of how to reduce risk factor(s) • Impact of general health on ability to change the risk factor(s) • Impact of social aspects of life on ability to change the risk factor(s) • Impact of emotions on ability to change the risk factor(s) • Patient and clinician: • Develop an action plan to address risk factor(s)

37. Policy Changes

38. Policy Changes

39. Policy Changes

40. The Health System Needs to Change “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things…” - Nicolo Machiavelli, The Prince

41. Key to Success Chronic disease prevention and management can’t be an add-on to someone’s current job

42. Key to Success Don’t need everyone involved in the initial planning

43. Key to Success Paradigm shifts take time

44. Key to Success Expect the unexpected…

45. ‘Nothing is more powerful than • an idea whose time has come’ • Victor Hugo