Ontario’s Chronic Disease Prevention and Management Framework

1. Ontario’s Chronic Disease Prevention and Management Framework Marjorie Keast, MOHLTC May 14th, 2007 Ontario Patient Self-Management Network

2. Outline of Presentation • CDPM Framework - The Purpose • Chronic Disease - The Issue • Chronic Disease Prevention and Management: The Evidence • The Transformation to Chronic Disease Prevention and Management • Ontario’s Framework for CDPM • Moving Forward

3. CDPM Framework - Purpose • To provide a common policy framework to guide efforts toward effective prevention and management of chronic diseases • To guide Ministry transformation initiatives such as: • Local Health Integration Networks • Primary Health Care Renewal, Family Health Teams • Public Health Renewal - health promotion and prevention initiatives • e-Health strategy, HHR strategy • Specific chronic disease strategies • To engage ministry stakeholders in a systematic approach to addressing chronic disease

4. Chronic Disease - the Issue • Ontario - economic burden of chronic disease estimated at 55% of total direct and indirect health costs (EBIC 2002) • Almost 80% of Ontarians over the age of 45 have a chronic condition, and of those, about 70% suffer from two or more chronic conditions (CCHS 2003) • Left untreated, chronic diseases can worsen, and predisposes to other conditions. • Yet…the current system is designed to treat and cure acute illness, not prevent nor manage chronic illness

5. Chronic Disease - the Issue • Ontario’s health system doesn’t do CDM very well: • 58% of diabetes patient are tested for HbA1C,,and of those tested, less than 50% had optimal blood glucose levels • 49% of diabetics have gone >1yr without an eye examination • 7.2% of AMI patients in Ontario are readmitted with 28 days – compared to 4.8% in Alberta • 53% of people with asthma are not properly controlled • With effective prevention and management of diabetes, asthma, congestive heart failure and depression, Ontario could avoid an estimated: • 29,000 emergency department visits • 67,300 hospitalizations, and • $200 - $350 million annually, in hospital costs

6. Causes of Death in Ontario, 2000-01

7. Real Causes of Death(JAMA 2004;291:1238) Poor diet to Inactivity ratio: Approximately 1.5 : 1

9. What Makes People Healthy / Unhealthy?

10. Preventing Chronic Diseases Improves Outcomes • 90% of type 2 diabetes, 80% of coronary heart disease, and one-third of cancers can be avoided by changing to a healthier diet, increasing physical exercise, and stopping smoking (WHO, 2003) • 80%-90% of COPD could be avoided by the elimination of cigarette smoking • Daily diets high in vegetables and fruit reduce cancer incidence by an estimated 20% • If 70% of women between ages 50 and 69 had mammography screening, approximately one-third of breast cancer deaths in Ontario could be prevented over a 10-year period • Colorectal screening by fecal occult blood testing could reduce mortality by 15%-33% in the 50-75 year age group, and 90% of cervical cancer is preventable with regular screening Keeping people well and preventing disease is the most cost-effective, affordable and sustainable strategy for coping with chronic disease

11. Managing Chronic Diseases Improves Outcomes and Decreases Costs • Multi-disciplinary, community-based Latino diabetes self-care clinic delivered with Latino health professionals licensed outside Ontario yielded 14% absolute reduction in blood glucose levels within one year (London InterCommunity Health Centre) • A COPD self-management education program reduced hospital admissions by 40%, emergency room visits by 40%, and improved health related quality of life (Bourbeau J,et al. Arch Int Med 2003;163:585-91) • Congestive heart failure discharge program reduced number of readmissions by 68% in first 9 months by coordinating care & educating clients, families (Group Health Centre, Sault Ste. Marie)

12. Managing Chronic Diseases Improves Outcomes and Decreases Costs (continued) • Veterans Health Administration by focusing on primary and ambulatory care reduced hospitalizations, leading to a reduction in acute operating beds from 52,000 to 19,000 over a 7-year period and a drop of about 60% in average daily inpatient population. (Department of Veterans Affairs, Program Statistics April 2003) • Kaiser Permanente achieved the following results over a 10 year period by using: a multidisciplinary steering group, physician champion for each guideline; registries, reminders, outreach programs, and empowering local clinicians: • 30% lower heart disease mortality than other plans • 15% decrease in death rates from CHF between 1996-2001 • smoking rate among N. California KP members was 12% compared to 18% for state as a whole (Kaiser Permanente)

13. The Transformation TO Wellness orientation • prevention at all points of continuum • an integrated, interdisciplinary care team approach • patient centred • proactive, complex, continuing care • individuals empowered for self-management and part of care team • FROM • Illness orientation • prevention not a priority • a solo provider approach • Provider, disease centred • reactive and episodic care • limited role for individuals in management A System Involving Health Care Organizations Individuals and Families Communities

14. A CDPM Systems Approach Has the Potential to Achieve • Fewer people with chronic diseases • Better clinical outcomes, longer more functional life • Increased efficiency in the system, quality care in the appropriate setting by the appropriate provider at the right time • Reduced hospitalizations, reduced use of emergency departments and reduced duplication of services • Increased healthy behaviours

15. 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

16. Framework Components Health Care Organizations -make systematic efforts to improve prevention and management of chronic disease: • strong leadership(e.g., CDPM champions) • alignment of resources, incentives(e.g., OMA agreement, Admin support, IT support for providers, etc.) • accountability for results(e.g., set goals, measure effectiveness in improving outcomes for clients, population and system )

17. Delivery System Design - focus on prevention and, improve access, continuity of care and flow through the system: • interdisciplinary teams(e.g., defined roles & responsibilities) • integrated health promotion and disease prevention(e.g., nutrition and physical activity counselling) • planned interactions, active follow-up(e.g., care paths, case management) • adjustments, innovations in practice(e.g., group office visits, central appointment booking service) • outreach and population needs-based care(e.g., Latin American Diabetes)

18. Provider Decision Support- integrate evidence-based guidelines into daily practice: • easily accessible clinical practice guidelines(e.g. web-based, interactive) • tools(e.g. disease/risk assessment, management flow sheets, drug interaction software) • provider alerts and reminders(e.g. reminders for tests, examinations) • access to specialist expertise(e.g. team social worker; cardiologist at tertiary care centre) • provider education(e.g. working in interdisciplinary teams, collaboratives) • measurement, routine reporting/feedback, evaluation(e.g. continuous quality improvement loop for target blood glucose levels in client population with diabetes)

19. Information Systems– are essential forenhancing information for providers to provide quality care; for clients to support them in managing their disease on a day to day basis; and for integrating services across health system: • electronic health records(e.g. personal health information, test results, prevention and treatment plans) • client registries to identify and provide patient subpopulations with proactive care, monitoring, and follow-up(e.g. tracking systems, automated reminders) • links(e.g. between team members, care centres) • information for clients(e.g. health care advice, access to records, community resources) • population health data (e.g. demographic, health status, risks)

20. Personal Skills & Self-Management Support -empower individuals to build skills for healthy living and coping with disease: • emphasizing the individual’s and families’ central role in their health, and as a member of the care team • engaging them in shared decision-making, goal-setting and care planning • providing access to education programs & health information (e.g. asthma education programs, consumer information) • behaviour modification programs (e.g. smoking cessation) • counselling and support services (e.g. self-management support groups) • integration of community resources (e.g. referral to community physical activity programs) • follow-up (e.g. reminders, self-monitoring assistance)

21. Healthy Public Policy- develop and implement policies to improve individual and population health and address inequities: • legislation, regulations(e.g. smoking by-laws) • fiscal, taxation measures(e.g. lowering duty on imported fruit) • guidelines(e.g. Health Canada food guidelines, screening) • organizational change(e.g. flex hours, day care in the workplace)

22. Supportive Environments- remove barriers to healthy living and promote safe, enjoyable living and working conditions: • physical environments (e.g. safe air, clean water, accessible transportation, affordable housing, walking trails, bicycle lanes) • social and community environments (e.g. daily physical activity in schools, seniors programs in community centres, on-site health promotion programs in the workplace)

23. Community Action- encourage communities to increase control over issues affecting health: • collaboration between the health care sector and community organizations(e.g. Latin American Diabetes Program, London ON) • effective public participation and intersectoral collaboration (e.g. community members, private sector and schools providing breakfast nutrition/physical activity programs)

24. 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

25. What Characterizes a “Prepared, Proactive Practice Team”? Prepared, Proactive Practice Team At the time of the visit, they have the consumer information, decision support, people, equipment, and time required to deliver evidence-based clinical management, health promotion/prevention, and self-management support* *adapted from MacColl Inst. for Healthcare Innovation, Group Health Cooperative of Puget Sound

26. What Characterizes “informed activated individuals & families”? Individuals understand the disease process, are part of the care team, and realize his/her role as the daily self manager. Family and caregivers are engaged in the individual’s self-management. The provider is viewed as a guide on the side, not the sage on the stage* *MacColl Inst. for Healthcare Innovation, Group Health Cooperative of Puget Sound Informed, Activated Individuals & Families

27. What Characterizes “Activated Communities & prepared, proactive community partners”? Communities are collaborating across sectors and with health care organizations to identify and meet the needs of their population. Individuals and families are linked to community resources Activated communities & prepared, proactive community partners

28. Moving CDPM Forward • MOHLTC Interministerial Committee • recommend priorities • alignment with CDPM best practices • enhance integration and coordination • CDPM Inventory and Survey Instrument • Priority Setting Tool for Chronic Diseases • Preventing and Managing Chronic Disease – Ontario’s Framework • CDPM Tool Kit for LHINs • Long-Term Strategy for CDPM – 1st Diabetes

29. CDPM Inventory - Survey Tool - involved three levels of information to map and analyze alignment of MOHLTC and MHP initiatives to the CDPM Framework i. Defined roles and responsibilities for team members a. Interdisciplinary Teams ii. Defined expertise and scope of practice of team members 1. Health Care Organizations iii. Knowledge of/or training in collaborative interdisciplinary practice for team members” b. Clinical Case Management Services 2. Delivery System Design c. Planned and Proactive Interactions iv. Formal links to access the right skill sets at the right time 3. Personal Skills & Self-Management Support d. Active Client Follow-up v. Defined leadership for interdisciplinary team 4. Provider Decision Support vi. Client membership on care team e. Outreach Activities CDPM Framework vii. Responsibilities of the interdisciplinary team for health behaviour and health education skills development 5. Information Systems f. Population specific needs 6. Community Action • Survey responses were analyzed with respect to: • Mapping: The number of initiatives where at least one Best Practice applied • Alignment: The number of initiatives where all or most of the Best Practices applied 7. Supportive Environments 8. Healthy Public Policy

30. Currently MOHLTC & MHP initiatives do not consistently apply best practice How well CDPM Best Practices were applied Community Action 76% Healthy Public Policy 71 % Personal skills + Self Mgmt Support 57% Delivery System Design 55% Provider Decision Support 48% Supportive Environments 41 % Health Care Organizations 37% Information Systems 27% OVERALL 51 % From Inventory or MOHLTC/MHP Inventory that mapped initiatives against the CDPM Framework 58 initiatives available at the time of data analysis

31. The major contributors to disease burden and costs in Ontario are heart disease, cancer, IHD, arthritis, stroke and diabetes PVA: Product of Actual Value of 7 Indicators* Developed by: Meera Jain, Population Health Policy Unit, PHPP&WHB , HSSD October 2005 Note: Missing data on Multiple Sclerosis and Urinary incontinence

32. CD as Comorbidity and Selected Risk Factors

33. A co-ordinated and integrated CDPM System supports Ontarians’ need to prevent disease and returns patients to lower intensity of care as efficiently and effectively as possible Level 4 Patients with Intensive Case Level 4 7.5% Complications Management (Optimize health status & coordinate ~ 15% of CD Level 3 17.5% pop ’ n ) Level 3 Care Management Disease poorly controlled (Care Plan Management ~ 35% of CD population) Level 2 75% Level 2 Self- Disease under reasonable control Management (Routine recommended care and self - management education ~ 50% of CD population) Support Level 1 100% Level 1 Health Persons at risk of Chronic Diseases Promotion 100% of population Stratification of population on the basis of level of need to ensure patient receives right care, by the right provider, at the right time, in the right place

34. Shared Professional Self Care Ratio of Shared Professional Care to Self Care across the Chronic Conditions population base Health Promotion NHS UK, Supporting People with Long Term Conditions

35. Level 4 Level 3 Level 2 Level 1 A co-ordinated CDPM System offers patients an appropriate suite of community and health systemservices depending on need Intensive Case Management Care Management Self Management Support Health Promotion • Level 1 (all Ontarians) • Goal: Prevent disease, engage in a healthy lifestyle • Will receive public education designed to address risk factors, self-management and reduce burden of disease • Will have access to a self-assessment tool/plan to determine their risk, and take action to prevent chronic disease • Will be linked to community resources, and groups with a focus on prevention and the determinants of health • Level 2 (all Persons with Chronic Diseases) • Goal: Maintain control of disease and empowerment of clients to self-manage • Managed with primary care providers according to best practice guidelines for applicable chronic disease, through use of: • Assessment, triaging • Disease Registry to track clinical targets • Provider Portal as an educational resource • General and disease specific self-management education, which is supported by: • Print materials • Client portal • Resource catalogue • Level 3 (Persons who require management) • Goal: Prevent complications and encourage self-management • Will be assessed, triaged and receive a care plan • Guided by a care management program: • Regular review of plan and proactive interventions to ensure meeting target • Access to right services from coordination services supported by resource catalogue • Follow-up reminders through telephone services • Level 4 (Persons who require intense management) • Goal: Prevent acute episodes, further complications and other co-morbidities • Will receive intense care management from an assigned case manager to ensure timely access to appropriate clinical and community resources

36. Thank You