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Gensichen J, Muth C, Schwäbe N, Gerlach FM

Gensichen J, Muth C, Schwäbe N, Gerlach FM. “HiMoL” A Tool for Case Management for Patients with Congestive Heart Failure in General Practice -  Feasibility Study EQuiP, Brussels November 11, 2004. Institute for General Practice Johann Wolfgang Goethe-University Frankfurt am Main.

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Gensichen J, Muth C, Schwäbe N, Gerlach FM

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  1. Gensichen J, Muth C, Schwäbe N, Gerlach FM “HiMoL” A Tool for Case Management for Patients with Congestive Heart Failure in General Practice- Feasibility StudyEQuiP, Brussels November 11, 2004 Institute for General Practice Johann Wolfgang Goethe-University Frankfurt am Main gensichen@allgemeinmedizin.uni-frankfurt.de Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  2. Congestive Heart Failure in General Practice • Congestive heart failure (CHF) will be the most serious cardiac health problem of the century (2–3 mill. in Germany) (Dietz 2003) • Only 20% obtain adequate treatment (Dietz 2003) • Discontinuity and mal-coordination of care (Moser 2000) ‘tyranny of the urgent’(Bodenheimer 2002) Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  3. Chronic Care Model Source: http://www.improvingchroniccare.org/change/model/components.html 10.06.2004 Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  4. Case Management ...Case Management is a clinical, educative, and social service provided to individualclients with high needs.(Wagner 2003) Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  5. Components of Case Management • Identificationof relevant patients • Assessmentof patients’ needs • Planof treatment • Co-ordination of care • Monitoring of effects(Norris 2002) Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  6. What are the effects of a phc-based Case Management on mortality of patients with CHF? • Review: (Gensichen et al. 2004) • 462 (studies) -> 23 (included) -> 7 (meta-analysis) • Mortality • Reduction in 6 months time - Relative Risk (RR) = 0.65 [0.44 – 0.94] • (QoL) • Improvement in 6 months time • (Costs/ Hospital days) • Reduction in 12 months time • Limitation:Selection, Outcomes, Setting Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  7. Case Management in “Berlin Practice Team Study” We are running a RCTto prove the effects of GP-based CM for patients with CHF (150 - 200 GP-teams and 1,500 patients) • Nurse-aids as Case Manager (CM)with a training in essentials of CHF and communication • CM is based at the general practice • CM offers a telephone-monitoring on symptoms and adherence • CM is the partner of the patient concerning questions on symptoms, side effects, and motivation for their adherence • After each patient contact CM and GP are planning next procedure together Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  8. HiMoL – Heart insufficiency (CHF) Monitoring List ... its targets: • Clinical assessment • Monitoring of adherence and outcomes ... it is a toolbox for the practice-team: • Checklistsand Manual for • Telephone monitoring • Outreach / home visits Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  9. HiMoLTelephone Checklist - Structure • 19 items • Clinical questions to the patient • + Feedback to the patient • + Assessment by the Case Manager • + Report to the doctor • + Doctor‘s information for the Case Manager • based on „EbM guideline for CHF in primary care“ (Muth 2004 in progress) • e.g. dyspnoe, orthopnoe, weight, symptoms on arrhythmia, infections and adherence Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  10. HiMoLTelephone Checklist - Action Stratified action based on urgency • Émergency -> stop the contact -> connect to the GP immediately • Urgency -> regular end of the contact -> consultation within 24h • Cave -> regular end of the contact -> special report to the GP • O.k. -> regular end of the contact -> regular report to the GP Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  11. HiMoLHome-Visit Checklist and Manual Home-Visit Checklist is idem to telephone checklist: • + Clinical data assessment • + Motivation for adherence Manual • Information for the Case Manager • Training-aid for the Case Manager Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  12. Evaluation of HiMol - Method • Step 1: expert processing Literature review, EbM-guideline CHF in PHC, draft • GP, MPH, M.Sc.Educ. • Physician, MPH, (cardiology) • Nurse-Aid, (Diploma in Health Education) • Step 2: users‘ check Interviews with 7 well-experienced Nurse-Aids • Step 3: feasibility study Test with GP-teams (4 rural, 1 urban); patients (14 NYHA II/III, 1 NYHA 1, 1 NYHA IV); 28 telephone contacts reported Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  13. Evaluation of HiMol - Results (1.) • Results: users‘ check • „The tool is clear, (...) practicable, (...) patient-centered, (...) self-explanatory, (...) improving the communication of the team“ • Results: feasibility study - Nurse Aids • Comprehensibility (1-6, mean) = 1.75 • Workability (1-6, mean) = 1.8 • Appropriate layout (1-6, mean) = 1.75 • Results: feasibility study – GP • Clearness (1-6, mean) = 1.75 • Workability (1-6, mean) = 2.5 • Useful for patient (1-6, mean) = 2.8 Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  14. Evaluation of HiMol - Results (2.) • Results: feasibility study - qualitative data (28 telephone reports): • 1 x other intercurrent diseases • 1 x syncope • 1 x irrregular heartbeat • 1 x adherence trouble • 6 x symptoms of infection Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  15. Evaluation of HiMol - Limitations • Selection of highly motivated praxis-teams • Small-sized sample • No controlled study-design • Validation study is needed Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  16. HiMol - Conclusions • HiMolis a tool to improve the process of care for patients with CHF • It is of practical use in the daily work of a GP-team • It is providing relevant clinical information to the GP THANK YOU! Who wants to check HiMol with his practice-team? gensichen@allgemeinmedizin.uni-frankfurt.de Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

  17. A n n o u n c e m e n t Disease Management, Case Management, and Chronic Care New Challenges and Chances in General Practice Frankfurt a.M., Fall 2005, Phone: +49 (0)69 6301 5687 gensichen@allgemeinmedizin.uni-frankfurt.de Institute for General Practice, Johann Wolfgang Goethe-University, Frankfurt, 2004

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