dh chronic disease management; the growing problem and strategic response 1

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).


2

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.


3

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””..


4

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


5

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


6

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+


7

And it is likely to continue rising because


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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%


9

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 )


10

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


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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


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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


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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…


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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?


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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


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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


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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


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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



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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.


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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


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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


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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


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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.


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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.


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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




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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


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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.


31

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.


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


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


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


35

The NHS moves from…

EFFECTIVE CHRONIC

DISEASE MANAGEMENT


36

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

dh chronic disease management; the growing problem and strategic response 1

Documents

growing problem

strategic response

dh chronic disease management