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Service Frameworks

Service Frameworks. What They Are & How to Use Them. Glenn Kissmann and Todd Gale. February 2006. Overview. Part I What is a Service Framework? Part II What is the COPD Service Framework?. Part I. Definition Development of the Service Framework Guide Why Use a Service Framework

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Service Frameworks

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  1. Service Frameworks What They Are & How to Use Them Glenn Kissmann and Todd Gale February 2006

  2. Overview Part I What is a Service Framework? Part II What is the COPD Service Framework?

  3. Part I • Definition • Development of the Service Framework Guide • Why Use a Service Framework • Service Frameworks Explained • Key Messages

  4. ‘Service Framework’ Defined • A patient-centered approach to improving health outcomes across conventional boundaries in the health system. • Attributes include: • Patient-centered decision making/goal setting • Describe optimal service delivery from a patient’s perspective • Includes the broader determinants of health • Encourages community and business sector involvement • Promotes collaborative working relationships

  5. Development of the Service Framework Guide in BC • International movement in this direction • UK, Australia, New South Wales • Current guide is made up of elements from other guides, using a BC context • Structure Provincial Steering Committee Provincial COPD Working Group IH COPD Working Group

  6. Why move to a Service Framework model? • Health needs of our population are moving from acute episodic needs to chronic care need • Increasing prevalence of chronic conditions • Delivery systems have not kept pace with changes in evidence and technology • Chronic care delivered in poorly connected episodes of care is less than optimal • Health system was not designed for long term chronic conditions • In our shifting paradigm, care delivered in familiar silos is not working

  7. Why move to a Service Framework model? Expected Results: • Improved patient satisfaction • Patient-focused care based on the best available evidence • Improved health outcomes • Increase capacity of the health system to manage chronic conditions • Reduced health system utilization • Quality care across the health-care continuum • Affordable and sustainable health-care system

  8. Service Framework Components • Scope – identifies the topic • Guiding Principles – core values of the framework • Rationale – why are we doing this • Standards of Care – a patient-centered approach suggesting what care should be expected • Performance Indicators – process and outcome • Research and Evidence – a living process

  9. Service Framework Explained

  10. Levels of Health Status Staying Healthy Getting Better Living with Illness Coping with End of Life

  11. Levels of Health Status • Planning across the health continuum • Staying Healthy – maintaining health and wellness • Getting Better – improving exacerbations or acute events in a chronic condition • Living with Disease – remaining stable and successfully managing a chronic condition • Coping with End of Life – preparing for death with dignity • Levels of health status were recently adopted by the BC Ministry of Health to guide health planning in BC

  12. Levels of Health Care Individual Care Providers Support System Health Care Environment

  13. Key Messages Service Frameworks are: • Theoretically sound but yet unproven • Patient-centered • Evidence-based • Service frameworks provide a systematic method of designing a health delivery systems/processes (a way of thinking and connecting the continuum of care) • A living process

  14. Part 2

  15. Part 2 - COPD Service Framework 1. Developing Standards of Care 2. Getting Better 3. Coping With End of Life 4. Key Messages

  16. Ours is a work in progress…

  17. 1. Developing Standards of Care

  18. Simple Outline of our COPD Framework

  19. Standards of Care

  20. Recommendation Sources

  21. Levels of Evidence

  22. Levels of Evidence: Research-based

  23. Levels of Evidence: Expert

  24. Need to Address Patient Populations

  25. A Spectrum Within a Continuum

  26. What do Highly Complex Patients Look Like ?

  27. Characteristics of A Highly Complex COPD Patient • Tend to be frail, elderly & have ADL issues • Comorbidities (other chronic diseases and conditions plus multiple medical problems) • Inadequate social, financial and emotional supports • Many medications • May have psychological dysfunction • Frequent use of both primary & secondary care resources for exacerbations of COPD

  28. Recommendations may come from the various roles and responsibilities within the Community of Practice Health Care Stage

  29. Recommendations should: • Be in line with the tenets of a quality system • Encompass all of ECCM constructs • Engage all of the players within the community, acute and primary care networks plus policy makers, physicians, patients and families. Forge collaborative partnerships – build bridges across the continuum • Utilize population health approaches to prevention, determining needs of patient populations and assessing quality of care • Use evidence-based decision making

  30. Recommendations should: • Provide services information & programs that are derived from patients needs • Promote self-management and an enhanced role of the patient, family and peers in decision-making and patient education. • Address improving access to health information. “information is a form of care” – Don Berwick

  31. 2. Getting Better

  32. Goals of the Standards of Care • COPD Exacerbations (Flare ups) • Flare up management in Primary care • Flare up management in Secondary care • Specialist care • Stopping smoking • Pulmonary Rehabilitation • Comorbidities: CHF, anxiety, depression, panic disorder and osteoporosis

  33. Dying trajectory of end-stage chronic diseases such as COPD and CHF

  34. COPD Flare ups • Flare ups are the most frequent cause of medical visits, hospitalizations and death in COPD patients • Most COPD patients have 2-3 flare ups/year • Antibiotic treatment failure rate is 17-32% with great cost • There is increasing evidence that most flares can be managed in primary care with support and education 1. Canadian guidelines for the management of acute exacerbations of chronic bronchitis: Executive summary. M. Balter,J.Forge,D.Low MD. Canadian Resp Journal July/August 2003, Vol 10, Number 5 2. Randomized controlled trial of supported discharge in patients with exacerbations of COPD E Skwarskaa,G Cohenb, K M Skwarskia, et al. Thorax 2000;55:907-912 (November)

  35. Defining A COPD Flare Up • No standard definition exists • No characteristic laboratory, radiographic or physiological tests for flare ups • In Canada, the most widely accepted clinical definition is from Dr. Nick Anthonisen: (From baseline) • increased sputum volume • increase in sputum purulence • increase in level of breathlessness A flare up = at least 2 of the above when focal findings of pneumonia etc. not present • No stethoscope is needed !

  36. What is a Flare up Action Plan? • An agreement between the patient and their physician how they will manage COPD flare ups. • A means for providers and patients to assist the physician management of COPD flare ups and improve QOL.

  37. Flare up Action Plan

  38. 3. Coping With End of Life

  39. Contrast the ethics of malignant versus nonmalignant diseases The Cancer Diagnosis: • empathy- “run for the cure” • is culturally engrained • palliation, morphine, a timeline • get your affairs in order

  40. Contrast the ethics of malignant versus nonmalignant diseases The Non Cancer Diagnosis: • curative expectation • lifestyle induced (tobacco, inactivity) • No definitive time line • “Heroic Measures” • Open heart surgery • Stent placing • Med-evacuation • Transplants • CPR

  41. Predicting death in nonmalignant clients • We lack tools to best predict time of death • There is strong argument for offering palliation to anyone who, in all probability, is likely to die within the next 12 months • Best apply the principles of palliative care on the basis of need rather than diagnosis

  42. Four Simple Points to Consider Four main issues are common to most Patients who are expected to live less than 12 months: • Deficits in basic self-care • Emotional distress • Pain and chronic symptoms • Malnutrition Stewart S, McMurray JJ. Palliative care for heart failure; Br Med J 2002;325:915-6.

  43. Key Messages about the COPD Service Framework: • Offers a means to promote seamless care within the continuums of COPD prevention to end-of-life and community to hospital. • In essence is a set of recommendations for the Community of COPD practice • Also…. Please don’t smoke !

  44. Thanks !

  45. Private IHWG web site http://www.qrp.pops.net/iha_wg/wg.htm

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