How do we Re-tool Ontario’s Health Care System for Chronic Disease Management and Prevention?

1. How do we Re-tool Ontario’s Health Care System for Chronic Disease Management and Prevention? INET International Michael M. Rachlis MD MSc FRCPC www.michaelrachlis.com Toronto June 20, 2007

2. Outline • Chronic disease has a major impact on our health and health system • Our health system doesn’t deal with chronic diseases very well • Some examples of chronic disease management excellence • How will Ontario’s health reforms affect chronic disease management and prevention

4. Chronic disease has a major impact on our health and health system • Chronic diseases account for 70% of all deaths. • Chronic diseases account for more than 60% of health care costs.

5. Ontario prevalence of chronic conditions Source: CCHS 2003 data

7. Chronic diseases: Common Risk Factors • The Social Determinants of Health, especially work and life strain • Unhealthy behaviours • Smoking, other drugs • Diet • Physical Exercise

8. Disparities in health between different groups are responsible for 20% of health care costs Health Disparities Task Group of the Federal Provincial Territorial Advisory Committee on Population Health and Health Security. Health Disparities: Roles of the Health Sector. 2004. http://www.phac-aspc.gc.ca/ph-sp/disparities/pdf06/disparities_discussion_paper_e.pdf

9. Outline • Chronic disease has a major impact on our health and health system • Our health system doesn’t deal with chronic diseases very well • Some examples of chronic disease management excellence • How will Ontario’s health reforms affect chronic disease management and prevention

10. Evidence of Ontario’s performance in Chronic Care • Fewer than 60% of Ontarians with diabetes have had a HgbA1c within the past year. • Only 50% of Ontarians with diabetes have an eye examination within one year of diagnosis. • 1 in 7 Ontario patients newly diagnosed with heart failure are re-admitted to hospital within 90 days of discharge and nearly one-quarter are re-admitted within one year.

11. Evidence of Canada’s performance in Chronic Care • Nearly 60% of Canadians with asthma had an uncontrolled outbreak in the previous year • 59% of Canadians who were depressed in the previous year did not receive mental health services despite over 90% having seen a family doctor • A study in Ottawa reported that one in six seniors was re-admitted to hospital within 30 days of discharge

12. If you can’t measure it, you can’t manage it: Registries are fundamental for chronic disease management and few Ontario doctors have them.

13. Canadian MDs don’t have registries Percent reporting very difficult or cannot generate Source: Schoen 2006

14. Canadian MDs don’t give care plans Percent giving written plan Source: Schoen 2006

15. Canadian interdisciplinary Teams are rare Source: Schoen 2006

16. We could prevent most chronic diseases • > 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 2900 acute hospital beds Ontario

17. 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.

18. Commonwealth Fund Rankings High Med Low K. Davis et al Commonwealth Fund pub no 1027 May 2007

19. Trying to deliver health services without adequate primary health care is like pulling your goalie in the first period!

20. Outline • Chronic disease has a major impact on our health and health system • Our health system doesn’t deal with chronic diseases very well • Some examples of chronic disease management excellence • How will Ontario’s health reforms affect chronic disease management and prevention

21. Chronic Care Model http://www.improvingchroniccare.org Resources and Policies Health System Health Care Organization ClinicalInformationSystems Community DeliverySystem Design Self-Management Support Decision Support Productive Interactions Informed, Activated Patient and Family Prepared, Proactive Practice Team Patient-centred Timely Efficient Coordinated Safe Evidence-based Improved Outcomes

22. Ontario’s CDPM Framework INDIVIDUALS AND FAMILIES Healthy Public Policy Personal Skills & Self- Management Support HEALTH CARE ORGANIZATIONS Supportive Environments Delivery System Design Information Systems Provider Decision Support Community Action COMMUNITY Productive interactions and relationships Informed, activated individuals & families Activated communities & prepared, proactive community partners Prepared, proactive practice teams Improved clinical, functional and population health outcomes

23. Assessing your Readiness for Chonic Disease careAssessment of Chronic Illness Care (ACIC) Version 3.5Http://www.improvingchroniccare.org/ACIC%20docs/ACIC_V3.5.doc

24. Assessment of Chronic Illness Care • Health care organization • Community linkages • Self management support • Decision support • Delivery system design • Clinical information systems • Integration of Chronic Care Model Components • Prevention • Public Policy

25. Organization of the Health Care System: Think of the US Veteran’s Health Services • Replaced 173 autonomous hospitals with 22 integrated regional networks . • Decreased hospital utilization by 62% • Increased overall number of patients by 18% • Increased ambulatory visits by 35% • Decreased costs by 18% • Increased colorectal cancer screening from 34% to 74% • 93% of diabetics have had a recent HgbA1C, 70% have had a recent foot exam • Discontinued 72% of forms

26. Veterans Administration bibliographyArmstrong B, Levesque O, Perlin JB, et al. Reinventing Veteran’s Health Administration: Focus on Primary Care. Journal of Healthcare Management. 2005;50(6):399-408.Arnst C. The best medical care in the US: How Veterans Affairs transformed itself and what it means for the rest of us. Business Week Online. June 2006. Found at: www.businessweek.com/print/magazine/content/06_29/b3993061.htm?chan=gl. Accessed November 7, 2006.Asch SM, EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and Patients in a National Sample. Annals of Internal Medicine. 2004;141:938-945.

27. Community Linkages: Think of the London InterCommunity Health Centre Latin American Diabetes Program • Adult Saturday screening program • IGT intensive risk management and prevention program • Children’s diabetes risk assessment program • Children’s intensive risk management program • Diabetes complication prevention program • Diabetes specialist satellite clinic.

28. London InterCommunity Health Centre Latin American Diabetes Program • Multiple entry points, Flexible hours • Multi-lingual, culturally appropriate care • Community health workers • International health professionals • Integrated with primary health care • Dietician, Foot Nurse, Nurse Practitioner, Social Worker • Self-management support • IT support

29. Self-management support: Think of the McMaster Stonechurch Family Health Centre rehab project • Patients > 45 with chronic illness and > 4 visits to the practice during the previous year • Assessed by an OT and PT • Individual care programs integrated goals for exercise, nutrition, and stress management into their care plans • After 2 years, the rehabilitation patients had fewer falls and their caregivers reported less stress. Rehab patient used ~ $450 less hospital care

30. Decision Support: Think of the Hamilton Shared Care mental health project • 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

31. Delivery System design: Think of the Sault Ste Marie Group Health Centre • 30 family doctors • 30 specialists • 120 nurses • 50 other professionals • Electronic records

32. Clinical Information Systems: Think of the Sault and OSCAR (www.oscarmcmaster.ca) • Registries • Reminders to providers • Feedback • Information about relevant subgroups of patients needing services • Patient treatment plans

33. Prevention: Think of Kahnewake and Sandy Lake • Community-based action • Community-based research • Healthy Public Policy • Walking trails • Healthy food

34. Public Policy: Think of Cigarette Smoking and seat belts • Thousands of Canadians won’t die this year because smoking rates are less than one-half what they were in 1970 • Thousands of Canadians will avoid lifelong disability and chronic pain because of seat belt laws

35. Outline • Chronic disease has a major impact on our health and health system • Our health system doesn’t deal with chronic diseases very well • Some examples of chronic disease management excellence • How will Ontario’s health reforms affect chronic disease management and prevention

36. Ontario 2007 • The government made its own fiscal box • A first ever Ministry Strategic Plan • Local Health Integration Networks • Family Health Teams, CHCs, and primary health care reform • Chronic disease management • Wait list management

37. Ontario 2007 • New CCAC boundaries • Health Human Resources • Public Health Reform • Ontario Health Quality Council (ohqc.ca) • The Social Determinants of Health • Take a breath!

39. LHINs 2007

40. LHINs: Ontario’s Bold Step Forward? • With integrated models, the devil is in the details. What are the details? • The LHINs are due to get $ authority but will the Ministry let them have it? • Future of CCACs and hospitals? CHCs? • Will the LHINs put ALL services out to tender? • How will the LHINs be funded? History? Population? Needs?

41. LHINs: Ontario’s Bold Step Forward? • Relationships with physicians? • Relationships with public health? • Relationships with family health teams? • Will there be protected budgets for services to vulnerable groups? • Labour transition strategy?

42. Primary health care reform • Will the family health teams be able to achieve excellence in care? • The funding encourages and discourages care for chronic disease • Will the province use the network of > 70 community health centres to stimulate innovation in service design • The use electronic systems?

43. Facilitating Solutions • Fully integrated funding • True primary health care reform • Electronic health records • ↑↑↑ resources for training for staff and boards • Integrated planning for prevention by Public Health, LHINs, FHTS, CCACs, CHCs et al • Provincial government strategy for health care AND health

44. Attributes of High Performing Health Systems Ontario Health Quality Council. April 2006. (www.ohqc.ca) Safe Effective Patient-Centred Accessible Efficient Equitable Integrated Appropriately resourced Focused on Population Health

45. Summary: • Chronic disease has a major impact on Ontario’s health and health system • Ontario deals poorly with chronic diseases • There are examples of Ontario chronic disease excellence but spread is hard • We need to change the way we deliver care • The Ontario CDMP Framework and Ontario Health Quality Council's Attributes for a high performing heath system can help us plan

46. “Courage my Friends, ‘Tis Not Too Late to Make a Better World!” Tommy Douglas (per Tennyson)