CHRIS DOWSE PROGRAMME LEAD CHRONIC DISEASE MANAGEMENT

1. CHRIS DOWSE PROGRAMME LEAD CHRONIC DISEASE MANAGEMENT

2. Learning and evidence so far • What is a systematic approach to CDM? • Getting started

3. CASTLEFIELDS HEALTH CENTRE (UK) • 15% reduc’n unplanned admissions • 31% reduc’n hospital LOS (6.2 to 4.3) • Total hospital bed days fell by 41% • Significant savings • Better patient experience • Improved integration + more appropriate referrals

4. VETERANS ADMINISTRATION (USA) • 35% reduc’n urgent care visit rate • 50% reduc’n hospital bed days

5. EVERCARE (USA) • 50% reduc’n unplanned admissions without detriment to health • Significant reductions in medications • 97% family and carer satisfaction • High physician satisfaction

6. NHS-ADAPTED EVERCARE • 3% of target pop’n = 30% unplanned admissions for that age group • many admissions avoidable (urinary tract infection, dehydration) • 55-87% high risk pop’n not accesssing DNs & Social Services • polypharmacy

7. NW LONDON SHA Case mgt releases significant capacity • 29% total medical specialities bed days used by 65+ with 2+ unplanned admissions. • Reduc’n occupied bed days 7.5 -16.6% • = up to £1.15m for PCTs

8. NW LONDON SHA (cont) • Reduc’n A&E adult attendances 2-3% • Reduc’n GP activity for 75+ up to 53% home visits; 82% OOHs; 19% general appts. • To set up case mgt - £173k per PCT

9. THE TRANSFORMATION Traditional Model Chronic Care Model SICKNESS CARE MODEL (Current Approach - Physician Centric) • Care is Proactive • Care delivered by a health care team • Care integrated across time, place and conditions • Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology • Self-management support a responsibility and integral part of the delivery system Counsel re: Lifestyle Changes Deal with Acute Attack of Disease Review Labs Reinforce Positive Health Behaviours Access Social/Other Services Talk with Family Reassure Complete Forms Diagnose Review Care Plan General Referral Consultation 10 minutes Reviwe/Adjust Rx and Tx Review History Routine Preventive Care Modify and/or Negotiate Care Plans Source: KPCMI [21]

10. Level 3 Highly complex members Intensive or Case Management Level 2 High risk members Assisted Care or Care Management Usual Care with Support Level 1 70-80% of a CCM pop Population Management:More than Care & Case Management Redesigning Processes Targeting Population(s) Measurement of Outcomes & Feedback

11. COMPONENTS OF EFFECTIVE CDM (1) • Pop’n management & risk stratification • Effective registers and integrated records • Evidence based “care pathways” • Disease management and care co-ordination

12. COMPONENTS OF EFFECTIVE CDM (2) • Self care/self management - with information and support • Active management of at risk patients • Primary/secondary/social care co-ordination

13. KEY PRINCIPLES OF CASE MGT. • Enhancing PC team role thro’ multi-disciplinary approachStratifying patients for highest risk • Providing proactive care to patients with highest burdens of disease

14. KEY PRINCIPLES OF CASE MGT. • Professional, usually clinical, case managers co-ordinating Care Plan • Working across boundaries and in p/ship with secondary care clinicians and social services • Care Team managing patient journey proactively and seamlessly thro’ all parts of health & social care system.

15. BE SYSTEMATIC - GETTING STARTED • Identify CD pop’n within PC • Move to pop’n mgt - stratify for risk • Improve disease mgt: Care Plans; review/ recall/ reassessment; care co-ordination • Support self management throughout • Identify pop’n with highest burdens of disease [ 2+ unplanned admissions; 4+ meds; etc] • Apply case mgt principles - proactive care