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Chronic Care Management - innovative integration

Chronic Care Management - innovative integration. Allan Moffitt (amoffitt@cmdhb.org.nz) Health Roundtable Presentation 15/16 Jun 2005. Context. Programme. Outcomes. Key Components. Today’s Content. The Context. Context. Programme. Outcomes. Key Components. Why CCM?.

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Chronic Care Management - innovative integration

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  1. Chronic Care Management- innovative integration Allan Moffitt (amoffitt@cmdhb.org.nz) Health Roundtable Presentation 15/16 Jun 2005

  2. Context Programme Outcomes Key Components Today’s Content

  3. The Context

  4. Context Programme Outcomes Key Components Why CCM? • Growing burden of Chronic Disease • Changing the model of care • Acute Demand • Growth in disease • People with Diabetes doubling by 2018 • People with Renal failure growing at 17% pa • Growth in risk factors • Obesity – BMI increasing 4.2% per annum • Exercise (lack of)

  5. Context Programme Outcomes Key Components Why CCM? • Growing burden of Chronic Disease • Changing the model of care • Acute Demand

  6. The CCM Programme

  7. Context Programme Outcomes Key Components CCM – A Piece of the CD Jigsaw Population Health Self Management Maintenance Case Managmt CCM Eg Annual Get Checked Eg Group Education Eg Smokefree Legislation

  8. Context Programme Outcomes Key Components Acute Model Secondary Tertiary Primary Care (Capitation/GMS) Intensity of Intervention Self Care/Medication Public Health Severity of Condition

  9. Context Programme Outcomes Key Components For Chronic Disease? Secondary Tertiary Limited Integration Primary Care (Capitation/GMS) Acute based unstructured care Intensity of Intervention Poor Access Poor knowledge/focus Self Care/Medication Public Health Severity of Condition

  10. Context Programme Outcomes Key Components Chronic Care Today Secondary Tertiary CCM Intensity of Intervention Primary Care (Capitation/GMS) Self Care/Medication Public Health Severity of Condition

  11. Context Programme Outcomes Key Components Chronic Care Today Secondary Tertiary Shared Information CCM Structured care for Identified Patients Intensity of Intervention Primary Care (Capitation/GMS) Reduced Co-pays Patient Held Care Plans Regular reinforcement Self Care/Medication Public Health Severity of Condition

  12. Chronic Care Today Secondary Tertiary Shared Information CCM Structured care for Identified Patients Intensity of Intervention Primary Care (Capitation/GMS) Reduced Co-pays Patient Held Care Plans Regular reinforcement Self Care/Medication Public Health Severity of Condition

  13. Chronic Care Today Secondary Tertiary Secondary Tertiary Shared Information CCM Structured care for Identified Patients Intensity of Intervention Primary Care (Capitation/GMS) Reduced Co-pays Patient Held Care Plans Regular reinforcement Self Care/Medication Public Health Severity of Condition

  14. Chronic Care Today Secondary Tertiary Shared Information CCM Structured care for Identified Patients Primary Care (Capitation/GMS) Intensity of Intervention Reduced Co-pays Patient Held Care Plans Regular reinforcement Self Care/Medication Public Health Severity of Condition

  15. Chronic Care Today Secondary Tertiary Shared Information CCM Structured care for Identified Patients GPs Nursing CHWs Primary Care (Capitation/GMS) Intensity of Intervention Primary Care (Capitation/GMS) Reduced Co-pays Patient Held Care Plans Regular reinforcement Self Care/Medication Public Health Severity of Condition

  16. Context Programme Outcomes Key Components The CCM Programme • High need patients • 4 free practice visits per annum • 6 hours nursing time per annum • Structured notes • Embedded within practice computer software • Empowered primary care • Secondary outreach/training • Electronic decision support • Regular reporting on progress • Empowered Patients • Patient held care plans

  17. Made easy – no paper!

  18. Made easy – no paper!

  19. Made easy – no paper!

  20. Patient Level Decision Support

  21. Effective Electronic Reminders

  22. An illustration of the effect of Electronic Clinician reminders

  23. Practice Feedback(Selected Practice)

  24. DHB Level Feedback

  25. Outcomes

  26. Context Programme Outcomes Key Components HbA1c

  27. Context Programme Outcomes Key Components LDLs

  28. Latest Outcomes • Clinical improvement in • Smoking status, statin uptake, cholesterol levels • Inpatient Utilisation • Pre enrolment vs post enrolment increase however lack of control to compare against normal progression • Outpatient Utilisation • Decreased in fully engaged practices • General Practice Utilisation • Stable – no change • Practice Nursing - increase

  29. Summary:Key Components

  30. Context Programme Outcomes Key Components 1. The Innovation- Empowered Primary Care • Clinical Champions • Whitiora Diabetes Team • Secondary Consultants • Electronic Clinical Decision Support (Predict) • Structured notes • Embedded within practice computer software • Practice based (not GP based)

  31. Context Programme Outcomes Key Components 2. The Learning Platform:the innovation gap • Regular Reporting • To target the very high risk • Supports CQI process • Programme reports • CUBE • Facilitates the paradigm shift

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