dh chronic disease management; the growing problem and strategic response 1
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DH Chronic Disease Management; the growing problem and strategic response
1
Chronic disease management;the growing challenge and the strategic response
“Health care systems world wide are faced with the challenge of responding to theneeds of people with chronic medical conditions such as diabetes, heart failure and
mental illness”(World Health Organisation, 2002).
DH Chronic Disease Management; the growing problem and strategic response
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6600%% ooff aadduullttss iinn EEnnggllaanndd rreeppoorrtt aa cchhrroonniicc hheeaalltthh pprroobblleemm
Out of 59m there is: Diabetes Mellitus affecting 1.3m people with perhaps another million
undiagnosed. COPD affecting 600,000 people Asthma affecting 3.7m adults and 1.5m children Arthritis affecting about 8.5m in UK Epilepsy with 400,000 sufferers England & Wales (1998) Mental Ill Health affecting 1 in 6 of the population, including 1 in 10
children 8.8m people in England have long term illness that severely limits
their day to day ability to cope.
DH Chronic Disease Management; the growing problem and strategic response
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CChhrroonniicc ddiisseeaasseess aarree pprroobblleemmss wwhhiicchh ccuurrrreennttmmeeddiiccaall iinntteerrvveennttiioonnss ccaann oonnllyy ccoonnttrrooll nnoott ccuurree..
TThhee lliiffee ooff aa ppeerrssoonn wwiitthh aa cchhrroonniicc ccoonnddiittiioonn iissffoorreevveerr aalltteerreedd -- tthheerree iiss nnoo rreettuurrnn ttoo ““nnoorrmmaall””..
DH Chronic Disease Management; the growing problem and strategic response
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I don't always look after myself all the time … The truth is I am scared about the long term, I'm scared of going blind or having my legs chopped off. Self management is the cornerstone of diabetes care, however, you don't need to be an `expert patient' to take control of your own diabetes. You need a relationship with the right professionals
to help you understand all the issues, make the right decisions, and achieve the right balance."
What is it like having a chronic disease?Interview with Stuart Bootle, a GP who has had diabetes for 20 years
DH Chronic Disease Management; the growing problem and strategic response
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The number of people with chronic conditions is rising (Source; General Household Survey 2002)
All people reporting a chronic condition
21
24
2930
31 31
35
33 3332 32
35
20
22
24
26
28
30
32
34
36
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from 1998 is weighted)
Pe
rce
nt
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And rising at all ages
People reporting a chronic condition (by age)
0
10
20
30
40
50
60
70
80
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from1998 is w eighted)
% o
f sam
ple
0-4y
5-15y
16-44y
45-64y
65-74y
75+
DH Chronic Disease Management; the growing problem and strategic response
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And it is likely to continue rising because
DH Chronic Disease Management; the growing problem and strategic response
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The commonest chronic diseases are arthritis and rheumatism, and heart problems (including high
blood pressure).(Source BHPS 2002)28.0%
16.8%13.5%
11.2%8.9% 8.5% 8.2% 7.9%
5.1% 4.0% 3.5%
0.0%5.0%
10.0%15.0%20.0%25.0%30.0%
DH Chronic Disease Management; the growing problem and strategic response
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In th e U K o f th o se p e o p le w ith a lo n g s ta n d in g p ro b le m a ro u n d a q u a r te r h a v e3 o r m o r e p r o b le m s , m a k in g c a re fa r m o re c o m p le x .
P ro p o rt io n o f p e o p le w ith a c h ro n ic d is e a s e w ith 3 o r m o re p ro b le m s
2 6 %
7 4 %
3 o r m o re p ro b le m s
1 o r 2 p ro b le m s
(S o u rc e ; B r i t is h H o u s e h o ld P a n e l S u rv e y 2 0 0 1 )
DH Chronic Disease Management; the growing problem and strategic response
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Women are slightly more prone to report chronic conditions; social class has a bigger impact though…
(source General Household Survey 2002)
% people with a longstanding problem
41%
34%
30%
40%
32%30%
20%
25%
30%
35%
40%
45%
Manual worker Intermediateworker
Managerial andprofessional
worker
Women
Men
DH Chronic Disease Management; the growing problem and strategic response
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Chronic disease is probably the wrong term, as most people withlongstanding medical conditions also have other complex needsleading to other disabilities often requiring care from other sources,especially social care.
% of people with activity limitations
4
15
28
4252
67
01020304050607080
None one two three four 5+
number of chronic diseases
perc
ent
DH Chronic Disease Management; the growing problem and strategic response
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Many people have more than one chronic condition
Average number of chronic conditions (for those with a chronic condition)
[Source General Household Survey 2002]
1.3
1.5
1.71.8
1
1.2
1.4
1.6
1.8
2
16-44 45-64 65-74 75+
Age
Nu
mb
er
of
con
dit
ion
s
DH Chronic Disease Management; the growing problem and strategic response
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Health care professionals may only interact with people with achronic disease for a few hours a year…
the rest of the time patients care for themselves…
DH Chronic Disease Management; the growing problem and strategic response
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“The predominant acute disease paradigm is an anachronism. It is shaped on a 19th century notion of illness as a disruption
of the normal state produced by a foreign presence or external trauma,...
Under this model acute care is that which directly addresses the threat. …. In fact, modern epidemiology shows that the
prevalent health problems of today (defined both in terms of cost and health impact)
revolve around chronic illness.”Bob Kane
How is the NHS currently configured and
what problems does this create?
DH Chronic Disease Management; the growing problem and strategic response
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There are important differences between acute and chronic conditions
i
Acute disease Chronic illnessOnset Abrupt Generally gradual and
often insidiousDuration Limited Lengthy and indefiniteCause Usually single Usually multiple and
changes over timeDiagnosis and prognosis Usually accurate Often uncertainTechnologicalintervention
Usually effective Often indecisive; adverseeffects common
Outcome Cure possible No cureUncertainty Minimal PervasiveKnowledge Professionals
knowledgeable, patientsinexperienced
Professionals and patientshave complementaryknowledge andexperiences
i Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ. 2000; 320: 526-527
DH Chronic Disease Management; the growing problem and strategic response
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Poor CDM leads to wasteful use of high intensity resources. 80% of bed days in hospitals are currently used by emergency beds
Of the eleven leading causes of bed use in the
UK, eight are due to conditions that strengthened community care would lead to a
fall in bed use
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50% of bed day use is accounted for by only 2.7% of all medical conditions, most of which are chronic diseases.
(Source: HES data 2002)
Cumulative bed day use by ICD code
-
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
Cause of admission
Be
d d
ays u
se
d
50% of admissions are accounted for by 2.7% of all diseases
25% of admissions are accounted for by 0.67% of all diseases
DH Chronic Disease Management; the growing problem and strategic response
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Having one or more chronic conditions increases your need for health care disproportionately
Increased likelihood of needing to use health services with increasing no.s of chronic problems
0
1
2
3
4
5
GP consultations Inpatient days
Ra
tio
co
mp
are
d t
o n
o
pro
ble
ms
No problems
1 or 2 problems
3 or more problems
DH Chronic Disease Management; the growing problem and strategic response
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And in some cases a few patients with chronic conditions end up on the “revolving door”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
Percentage of inpatients
Cu
mu
lati
ve
pe
rce
nta
ge
of
inp
ati
en
t d
ay
s
10% of patients account for 55% of bed use
5% of patients account for 42% of bed use
DH Chronic Disease Management; the growing problem and strategic response
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What can we do?
CaseManagement
Specialist DiseaseManagement
Supporting care
And Self Care
Level 170-80% of aChronic disease pop
Level 2High riskpatients
Level 3Highlycomplexpatients
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Self-care works visits to GPs can reduce by over 40% for high risk groups
Fries J et al (1998) Reducing need and demand for medical services in high risk groups. West J Med 169: 201-207.
hospital admissions reduce by 50% in a Parkinson’s disease Montgomery et al (1994) Patient education and health promotion can be effective in Parkinson's disease: a randomised control trial. The American Journal of
Medicine Vol. 97: 429.
outpatient visits reduce by 17% generally Lorig et al (1985) A work place health education programme that reduces outpatient visits. Medical care 23, No 9: 1044-1054.
hospital length of stay reduce for mental health problems Kennedy M (1990). Psychiatric Hospitalizations of Growers. Paper presented at the Second Biennial Conference on Community Research and Action, East
Lansing, Michigan.
medication intake more appropriate (e.g. steroids in asthma) Charlton et al (1990) Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice BMJ 301: 1355-9.
A&E visits reduce significantly for patients with asthma Choy et al (1999) Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socio-economic status in Hong Kong. Clinical
Experimental Allergy 29: 84-90.
days off work can reduce by as much as 50% for people with arthritis
Fries J et al (1997) Patient education in arthritis: Randomised controlled trial of a mail delivered programme. Journal of Rheumatology 24, No 7: 1378-1383.
DH Chronic Disease Management; the growing problem and strategic response
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It gave me new ways of analysing and solving some of my problems... I believe that this is one of the most important
initiatives for those with long-term chronic conditions
The expert patient programme has really helped me to take more control of not just my arthritis, but also my life.
Coming on the programme has
given me real confidence to move on, plan for the future without fear, because I can now plan and pace—really good teaching.
I have learnt that I need to take responsibility for my health instead of leaving it all to my GP.
Quotes from the Expert Patient Programme
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Supporting chronic careTo do this we need to consider the
Three Rs;
Registration of a population of patients for whom primary care teams identify problems, co-ordinate care and help support their condition.Recall of people to ensure they get the care they need by using prompts and reminders.Review patients to ensure they receive the best evidence based care and are supported to manage their condition
DH Chronic Disease Management; the growing problem and strategic response
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Supporting chronic care
For most patients this care will come from
• their general practice
• community nurses
• pharmacists
• other members of the wider PCHT
DH Chronic Disease Management; the growing problem and strategic response
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Some patients with chronic conditions need more
• Some have a chronic condition that needs the occasional input of a specialist- often a community based (nurse) specialist- to avoid deteriorations and improve control: disease specific case management
• Others have a complex mix of social and medical problems, often leading to frequent re-admissions, unless they receive case management
DH Chronic Disease Management; the growing problem and strategic response
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Disease specific case management
There is good evidence about the impact of responsive community specialist services on specific conditions, for example
heart failure Department of Health. National Service Framework for Coronary Heart Disease. HMSO, 2000.And Doughty RN, Wright SP, Pearl A, Walsh HJ, Muncaster S, Whalley GA et al. Randomized,
controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. Eur Heart J 2002;23:139-46.And Knox D,.Mischke L. Implementing a congestive heart failure disease management program to decrease length of stay and cost. J Cardiovasc Nurs 1999;14:55-74.And Stewart S, Blue L, Walker A, Morrison C, McMurray JJ. An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it? Eur Heart J 2002;23:1369-78.
COPD and asthma Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-
specific self-management intervention. Arch Intern Med 2003;163:585-91.And Morrison DS,.McLoone P. Changing patterns of hospital admission for asthma, 1981-97. Thorax 2001;56:687-90.And Baker D, Middleton E, Campbell S. The impact of chronic disease management in primary care on inequality in asthma severity. J Public Health Med 2002;25:258-60.And Naish J, Sturdy P, Griffiths C, Toon P. Appropriate prescribing in asthma. BMJ 1995;310:1472.And Barbanel D, Eldridge S, Griffiths C. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. Thorax 2003;58:851-4.And Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA) [In Process Citation]. BMJ 2004;328:144.
diabetes Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev
2001;CD001481.And Sidorov J, Gabbay R, Harris R, Shull RD, Girolami S, Tomcavage J et al. Disease management for diabetes mellitus: impact on hemoglobin A1c. Am J Manag Care 2000;6:1217-26.And Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R. Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria. Diabetes Care 2002;25:684-9.And Vrijhoef HJ, Spreeuwenberg C, Eijkelberg IM, Wolffenbuttel BH, van Merode GG. Adoption of disease management model for diabetes in region of Maastricht. BMJ 2001;323:983-5.
and depression Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J et al. Disease management for depression and at-risk drinking via telephone in an older population of veterans. Psychosom
Med 2003;65:931-7.And Coyne JC, Brown G, Datto C, Bruce ML, Schulberg HC, Katz I. The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study. Int J Geriatr Psychiatry 2001;16:570-6.And Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002;325:951-4.And Roberts K, Cockerham TR, Waugh WJ. An innovative approach to managing depression: focus on HEDIS standards. J Healthc Qual 2002;24:11-64.
DH Chronic Disease Management; the growing problem and strategic response
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Case managementFor some patients a more holistic approach is
required.
They are often highly intensive users, or very highly intensive users of the health service, and simple problems amenable to early interventions (e.g. a fall or an acute infection) can lead to a rapid deterioration in their condition.
DH Chronic Disease Management; the growing problem and strategic response
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It is these people that largely make up the “5%”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
Percentage of inpatients
Cu
mu
lati
ve
pe
rce
nta
ge
of
inp
ati
en
t d
ay
s
10% of patients account for 55% of bed use
5% of patients account for 42% of bed use
DH Chronic Disease Management; the growing problem and strategic response
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Case managementBefore Case managementInitially presented in A&E 4 times over the last 3 months with falls
Care package, meals on wheels and personal alarm in situ
At risk of recurrent falls, poor transfer technique
Unable to access community transport or mobilise outdoors
Oedema in both lower legs
Older person felt lonely, isolated and depressed –
“I tell people what I need but they don’t hear me”.
After Case managementEasy-Care Assessment in own home. Listened to her voice and spent time understanding her needs.Contacted GP and District Nurse to review medication and to deliver incontinence pads.Spent time together to ensure receiving appropriate benefits.Arranged for mobile hairdresser and for ears to be pierced.Carried out a joint assessment with the Occupational Therapist.Put air into tyres of old wheelchair
DH Chronic Disease Management; the growing problem and strategic response
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How does it fit together?The Chronic Care Model
i
i Wagner EH. Chronic disease management: What will it take to improve care for chronicillness? Effective Clinical Practice. 1998;1:2-4.
DH Chronic Disease Management; the growing problem and strategic response
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PCTs need to work in partnership with other NHS Trusts (including ambulance trusts) and social care to develop integrated approaches to care. A key issue is the sharing of incentives to promote high quality care.
Many of the pieces are in place: The Expert Patient programme, NHS Direct and digital TV pilots, but some is patchy.
We must build on the use of evidence based guidelines for the treatment of chronic diseases and incorporate them in IT systems to make it easier to do the right thing.
We should build on the strengths of multidisciplinary team working (including social care) with a strong centre in primary care. The NHS could increase its use of risk stratification and case management of high risk patients.
PCTs need local strategic partnerships with local authorities, engaging community and voluntary organisations
PCTs need to work in partnership with other NHS Trusts (including ambulance trusts) and social care to develop integrated approaches to care. A key issue is the sharing of incentives to promote high quality care.
Many of the pieces are in place: The Expert Patient programme, NHS Direct and digital TV pilots, but some is patchy.
Remember the three Rs: IT should can support care planning, risk stratification, and monitoring the quality of care on offer. Information systems need to support the transfer of information.
We must build on the use of evidence based guidelines for the treatment of chronic diseases and incorporate them in IT systems to make it easier to do the right thing.
We should build on the strengths of multidisciplinary team working (including social care) with a strong centre in primary care. The NHS could increase its use of risk stratification and case management of high risk patients.
PCTs need local strategic partnerships with local authorities, engaging community and voluntary organisations
Remember the three Rs: IT should can support care planning, risk stratification, and monitoring the quality of care on offer. Information systems need to support the transfer of information.
DH Chronic Disease Management; the growing problem and strategic response
32
Patien
t
experi
ence
programme:
The Expert
patien
t
programme,
NHS Dire
ct
and digita
l TV
provide
resource
s for
patien
ts to
better
manag
e
their ca
re
Set of tools in each health community to create a health and
social care system to support people with a chronic problem
Payment by results:
Gives
commissioners a
means of releasing
funds from acute
care & encourages
trusts to reduce
LOS
Incentive scheme to encourage
social services to avoid delayed transfer of care
IT: Already the information systems are in place for Registration, Recall, and Review. At risk patient can be identified. The NPfIT will augment this and help the flow of information
New pharmacy contract:
Allows PCTs to broaden
services available in
the community
New GMS and PMS: The quality and outcomes framework rewards good CDM in ten important diseases.PMS+ and enhanced services gives PCTs the ability to build capacity for new chronic disease services
National Service Frameworks: Many
of the NSFs have obvious
implications for better CDM-
diabetes, CHD, older people,
mental health, children, renal
disease, long term neurological
conditions
Payment by results:
Gives
commissioners a
means of releasing
funds from acute
care & encourages
trusts to reduce
LOS
Incentive scheme to encourage
social services to avoid delayed transfer of care
IT: Already the information systems are in place for Registration, Recall, and Review. At risk patient can be identified. The NPfIT will augment this and help the flow of information
Patien
t
experi
ence
programme:
The Expert
patien
t
programme,
NHS Dire
ct
and digita
l TV
provide
resource
s for
patien
ts to
better
manag
e
their ca
re
New pharmacy contract:
Allows PCTs to broaden
services available in
the community
New GMS and PMS: The quality and outcomes framework rewards good CDM in ten important diseases.PMS+ and enhanced services gives PCTs the ability to build capacity for new chronic disease services
National Service Frameworks: Many
of the NSFs have obvious
implications for better CDM-
diabetes, CHD, older people,
mental health, children, renal
disease, long term neurological
conditions
DH Chronic Disease Management; the growing problem and strategic response
33
Other potential tools...
Use defined clinical care pathways
Integrate with social care, more inter-mediate care
Ensure savings made in one part of the system benefit all involved in chronic care
Commission care through clinical networks
Develop community clinical specialist (nurse led) teams
Practice incentives and commissioning
Use defined clinical care pathways
Integrate with social care, more inter-mediate care
Ensure savings made in one part of the system benefit all involved in chronic care
Commission care through clinical networks
Develop community clinical specialist (nurse led) teams
Practice incentives and commissioning
DH Chronic Disease Management; the growing problem and strategic response
34
Health care communities and the NHS as whole benefit because investing in chronic disease reaps
health and financial dividends . The Wanless report, Securing Our Future Health (Interim Report)
argued that for every pound invested in self care;
The economic case for disease management is more complex, but the improvement in quality of life is undeniable.
There is a growing evidence base on the possible financial effects of case management (mainly from abroad, but increasingly from the UK). This suggests that investing in primary and community care to support case management will free up scarce acute resources to use more appropriately.
around £1.50 can be reinvested more effectively
DH Chronic Disease Management; the growing problem and strategic response
35
The NHS moves from…
EFFECTIVE CHRONIC
DISEASE MANAGEMENT
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But most importantly, patients benefit...
Control of their own conditionFeeling of well beingAbility to cope day to day
Complications from their chronic diseaseUnnecessary hospital admissionsSense of powerlessness
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