Complex Chronic Disease Patients better results at a better cost

1. Complex Chronic Disease Patientsbetter results at a better cost Gerry Bédard, MD Alain Larouche, MD Guylaine Chabot, M.P.A. June 2012

3. PRESENTATION PLAN • The number one issue: complex chronic diseases • The Concerto health model • The showcase • An outstanding living laboratory • The implementation process

4. THE NUMBER ONE ISSUE • Complex chronic disease (CCD) • Complex chronic disease: several CDs affecting one patient • The accumulation of CDs: 25% of the population has two or more CDs • A pathological problem in itself: the diseases have a harmful synergistic effect on each other • Uncoordinated care: a harmful effect on complex CDs • Prevention: acting on health behaviours

5. Impact of chronic diseases on the health system % of people hospitalized according to condition NOTE People with 3 or more chronic diseases account for 71% of all admissions. Number of chronic diseases

6. Ratio population/expenditures according to condition • Impact of chronic diseases on the health system NOTE People with 5 chronic diseases or more (3% of the population) account for the same expenditures as people with no chronic diseases (52% of the population). Ratio population/expenditures Number of chronic diseases Source: Medical Expenditure Panel Survey 2001

7. Impact of chronic diseases on the health system • 3% of the population • 50% of inpatient days • Data validated for the entire Québec population • 5,000 FTE nurses required for this care

8. THE CONCERTO HEALTH MODEL • Description • Optimal, front-line care management of a population registered with a family medicine group (FMG) • Complete interdisciplinary team: physicians, clinical nurses, other professionals • Services adapted to patient categorization • Care and service pathways • Proven information system

9. Approach • Population health • Services offered close to the patient’s home • Holistic approach • Health prevention and promotion • Screening for chronic diseases • Priority given to chronic diseases • Categorization • Multimorbidity: complex chronic patient • Collaborative approach: interdisciplinary team with the patient

10. The cornerstone of the model • Chronic disease management pyramid • From the “Chronic Care Model” by Ed Wagner et al. • Improved (Canadian version)

11. 19 target diagnoses and conditions • Diabetes • High blood pressure (HBP) • Dyslipidemia • COPD • Asthma • Chronic heart failure (CHF) • Arteriosclerosis disease • Chronic renal failure (CRF)

12. 19 target diagnoses and conditions • Mental health • Depression • Anxiety disorders • Attention deficit hyperactivity disorder (ADHD) • Oncology and palliative care • Chronic pain • Dementia and loss of autonomy • Neonatal follow-up • Pregnancy follow-up • Regular medical exam • Screening • Prevention and promotion

13. Roles of health professionals • FMG • Offer access to continuous, quality services • Interdisciplinary team • Personalize the services offered • Optimize the family physician/clinical nurse duo (ongoing collaboration) • Foster the expertise potential of each professional

14. Roles of health professionals • Clinical nurse (university degree) • Provide personalized patient follow-up • Offer relevant instruction • Promote self-care • Coordinate care (key role) • Ensure smooth case management for complex patients

15. Roles of health professionals • Physician • Diagnose clinical conditions • Prescribe the care trajectories • Make sure of patient’s follow-up • Support the nurses and other professionals • Provide the periodic medical follow-up required

16. Roles of health professionals • Other professionals • Support the nurses according to the care trajectory • Participate actively in the care of patients at high risk of complications and with complex cases • Coordinate care and services with the other CSSS professionals • Front-line care • Specialized care

17. Roles of health professionals • Health and social services centre (CSSS) • Relocate health care professionals to FMGs • Validate collective prescriptions (director of nursing) • Coordinate activities in the region • Provide and coordinate access to services • Home care • Specialized clinics • Medical specialists • Technical support

18. Roles of health professionals • Concerto health group • Develop care and service pathways • Produce collective prescriptions • Categorize patients • Identify frequent users • Coordinate professional training • Support health care professionals in managing change • Organization of work • Professional practices • Adoption of computerized solutions • Evaluate and improve administrative processes on an ongoing basis

19. Tools • Care and service pathways based on consensus and relevant data • Screening • Clinical assessment • Teaching • Lab tests • Decision support • Treatments • Interprofessional references • Follow-up according to clinical condition

20. Tools • Technology platform • Interprofessional intervention tool • Exchange of information with patients • Patient portal • Telehomecare (telemonitoring and remote follow-up) • Database • Manage population data • Manage clinical processes • Manage results

21. Tools • Decision support • Collective prescriptions: sharing of reserved medical activities • Lab tests • Therapy adjustments • Report to physician

22. Training program for all professionals • Motivational approach • Éducoeur-en-route • Health coach • Collaborative approach: the real interdisciplinary work including the patient • Case management • Specifics and complications per pathology • Post-training support

23. Dynamic assessment • Dashboard • Clinical process tracking indicators • Accessibility • Continuity • Appropriateness • Productivity • Care quality • Satisfaction • Societal costs

24. Dynamic assessment • Dashboard • Outcome indicators • Behavioural changes • Empowerment • Improved state of health • Level of use of services • Emergency room stretchers • Hospital beds • Beds in long-term care centres (CHSLD)

25. Care pathways • Protocols • Collective prescriptions • Teaching Strategic clinical alliance CSSS Family physicians Front line Population Relocation of interdisciplinary team Personalization of care (multipathologies + comorbidities) Categorization IIIP + case management IIIP* Care trajectories Preventive screening *IIIP: Individualized interdisciplinary intervention plan

26. Chronic disease management system Coordination of care and services – THE CHALLENGE Population health management Health portal Telehomecare - telemonitoring

27. Interdisciplinary training Measuring satisfaction and quality of life Proactiveness Measuring societal costs Productive interaction Well-trained, proactive staff Well-informed patients and loved ones who are partners in care giving Teaching Lifestyle habits (Éducœur-en-route) Optimal medication management

28. THE SHOWCASE • Degree of progress • 17 months of activities • 2 FMGs in Sud de Lanaudière • Collaboration agreements • Ministry of Health and Social Services • Regional Health Board of Lanaudière • Sud de Lanaudière Health Center (CSSSSL) • Concerto Health Group

29. Interdisciplinary team • Family physicians (20) • Nurses (10 FTE) • Pharmacist (0.8 FTE) • Nutritionist (0.8 FTE) • Respiratory therapist (1.0 FTE) • Social workers (2 FTE) • Psychologist (0.8 FTE) • Physiotherapist (0.4 FTE) • Occupational therapist (0.4 FTE)

30. Among patients with at least one of the diagnoses, 68% have 2 or more diagnoses Patients with 3 diagnoses make up the largest group * including 544 patients investigated or monitored mainly for respiratory problems (not shown on the chart)

31. Degree of progress • 243 frequent users identified • 3 hospitalizations or more in 3 years • 5 events or more in 3 years • Interdisciplinary intervention plans • 65 completed in June 2012

32. Results: trends • Satisfaction among nurses with regard to training • High rate: > 80% • Continuity of care • 3 visits or more plus monitoring by the same nurse: 95.7% of patients

33. Table showing the change in patients’ state of health based on HbA1c analysis results (1st period 0 – 6 months) • 21.95% of patients improved their result. • 28.3% of patients maintained their result at the target level. • 37.9% of patients remained stable, but not at the target level. • 11.8% of patients saw their state of health deteriorate. Data gathered from October 2010 to February 2012 and produced on April 10, 2012.

35. Results: trends • CSSSSL efficiency gains: costs recovered after a little more than 3 years of operation • Overall efficiency gains (CSSSSL and network): costs recovered after 2 years of operation • In the longer term: reduction in the expenditure growth curve

36. Legal framework • Patient consent • Confidentiality rules governing personal information • Rules governing information access, retention and circulation • Rules for processing redacted information

37. Integrated Clinical Solutions Technology Partner Chronic Disease management Remote Patient monitoring Chronic Disease Management solution Personal Health records

38. Pharmaceutical partners • Sanofi • Astra-Zeneca • Bristol-Myers-Squibb • Pfizer • Shire • Interdisciplinary training program • Societal costs • Optimal medication management

39. Collaborators • Institut de recherches cliniques de Montréal • Éducoeur-en-route • Claude Sicotte, PhD: full professor, Faculty of Medicine, Université de Montréal • Dashboard • Fernand Couillard, MD, psychiatrist • Mental health care pathways

40. OUTSTANDING LABORATORY: Living Lab • Better informed and monitored patients: “chronically well” • Innovative, advanced clinical practices for nurses • Physicians better supported in their practice • Demonstrated efficiency of the front line in response to the health needs of the population • Added value for the network’s performance • Cutting-edge contribution for the evolution of health care systems