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Dr Jason Cheah
Chief Projects Officer
National Healthcare Group, Singapore
DISEASE MANAGEMENT:
SINGAPORE STYLE
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THE COMPARTMENTALISED “ILLNESS” CARETHE COMPARTMENTALISED “ILLNESS” CARE
Pre-illness Illness Post-illness
• Clinics, hospitals • Home Care Services• Nursing Homes
• Vaccination• Public Health Education• School Health• Workplace Health Promotion
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THE “HOSPITAL-WITHOUT-WALLS”THE “HOSPITAL-WITHOUT-WALLS”
Pre-illness Illness Post-illness
Health Maintenance• Vaccination• Public Health Education• Health Screening• Workplace Health promotion
Illness Care• Cost effective, efficient care
- systems processes - clinical pathways
Health Recovery• Skills-for-life• Homecare support• Follow-up support
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Brief on Singapore Healthcare System
• Dual care delivery system – public and private• Co-payments and use of Medical Savings Scheme• Hospital services utlise largest portion of NHE• Funding for public hospital services by DRG (in-patient
and day surgery) and per attendance basis (specialist outpatient clinics)
• Establishment of two public sector clusters to foster vertical integration of clinical services
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Megatrends
• Demographic transition – ageing population, decreasing total fertility rates
• Epidemiological transition – changing disease profiles to chronic diseases (diabetes mellitus – 9%, hypertension – 27% of adults)
• Demand for cost-effective healthcare services• Decreased information asymmetry and increased consumer
choices• Technology changes
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National Healthcare Group
Outpatient facilities:
- 2 National Centres – National Neuroscience Institute (NNI) & National Skin Centre (NSC)
- 9 Polyclinics – located at various housing estates in Singapore
Inpatient facilities:
- 1 Tertiary Hospital – National University Hospital (NUH)
- 2 Regional General Hospitals – Tan Tock Seng Hospital (TTSH) & Alexandra Hospital (AH)
- 1 Specialty Hospital _ Woodbridge Hospital (WH)
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Vision
Adding Years of Healthy Life to the
People of Singapore
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Mission
We will improve health and reduce illness through patient-centered quality healthcare that is accessible, seamless, comprehensive, appropriate and cost-
effective in an environment of continuous learning and relevant research
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Fragmentation of Healthcare System
Lower Costs Higher CostsHealthcare Spectrum
Self-directed Primary Secondary Tertiary Long Term
Preventive Strategies
Family PractitionersAllied healthprofessionals
Specialists HospitalsOutpatientClinics
Hospitals Centers of Excellence
InstitutionsNursing HomesHome Care
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Clinical Integration
Objectives
• To coordinate the entire continuum of primary, secondary and tertiary healthcare services.
Clinical integration extends both horizontally and vertically.
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Clinical Integration
Achieving clinical integration requires:
• Clinical leadership
• Availability of expertise
• Availability of resources
• Supportive management
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Definition of Disease Management (DM)
A clinical management process of care that spans the continuum of care from primary prevention to ongoing long-term maintenance for individuals with chronic health conditions or diagnoses. It identifies individuals with chronic diseases, assesses their health status, develops a program of care and collects data to evaluate the effectiveness of the process. It intervenes proactively with treatment and education so that the individual with a chronic disease can maintain optimal function with the most cost-effective and outcome-effective health care expenditure.
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Primary Objectives of DM
o Encourage disease prevention and maintenance of good health Promote correct diagnosis and treatment planning Maximize clinical effectiveness of interventions Eliminate ineffective or unnecessary care and interventions Eliminate duplication of effort and activity Utilize only cost-effective diagnostics and requirements Maximize the efficiency of healthcare delivery while maintaining
appropriate standards of quality Continually improve outcomes of the care delivery process
Emphasizes an evidence-based approach
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Requirements of a successful DM program Holistic/Team approach with healthcare professionals working
together in a cooperative and coordinated approach Understanding the course of the disease/practice guidelines Targeting patients likely to benefit from intervention Takes into consideration the total cost across the entire continuum
of care Appropriate information to the development & evaluation of “best
practice” for particular diseases Focusing on prevention and resolution Increasing patient compliance through education Providing full care continuity Audit must be integral part of medical practice Establishing integrated data management for outcome measurement Patient/Family involvement is critical
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Skills & Tools in DM process
Skills/Tools Process
Medical database – informationon clinical and cost-effectivenessof all interventions
Disease
Review evidence
Clinical expertiseeg peer review groups, patient advocates
Define good practiceguidelines (evidence-based)
Clinical management tooleg patient follow-up reminders to aid collection of relevant data
Data collection
Outcomes database – store, retrieve, analyze outcomes
Data analysis
Clinical expertise Review outcomes data
OUTCOMES
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Elements of Disease Management at the Mayo Clinic
Primary care practice guidelinesInformation SystemsContinuous quality managementResource management techniquesInformation managementSpecialty care managementHospital managementEmergency room managementPharmacy managementDiagnostic utilization managementCase managementPatient educationPrimary care teamsTriage system/telephone systemsBenefit design
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Conceptual Model of the Healthcare Providers who may be involved in DM plan
Self-directed care
BasicPrimary Care
Extended PrimaryCare
Secondary& TertiaryCare
Long-TermCare
SocialServices
PublicHealth Personnel
-Family Practitioners-PracticeNurses-Pharmacists-Laboratory Service Providers
-CommunityNurses-Counselors-Physiotherapists-Occupationaltherapists
-SpecialistsCenters of excellence-Other serviceproviders
-Institutional Care-Nursing Home-Home Care
-Housing-Employment-Income Support
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Developing a DM Plan
1. 1. Identify an appropriate disease / case type and team
2. 2. Determine current clinical practice
3. 3. Perform an economic analysis in terms of disease burden
4. 4. Identify key patient segments and target treatment groups
5. 5. Identify critical (failure) points
6. 6. Create a disease management plan (with key stakeholders)
7. Disseminate and reinforce the plan
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Systems-Thinking Model: The Disease Management Process
1. Build a Shared Vision
2. Establish a Shared Reality
PLANNING 3. Understand & Share Key Benefits
4. Identify Barriers to Change
5. Develop Strategic Options
6. Identify Leverage Options
7. Determine how to measure results
DESIGN
IMPLEMENTATION
8. Learn & ContinuouslyImprove
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Continuum of Care
Maintenance/RecoveryHealth Promotion
Disease Prevention
Disease Awareness/Symptom Recognition
Diagnosis
TherapyCompliance –Self Management
OutcomesMeasurement
Reintegration/Rehabilitation
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Data Sources for Developing Disease Models
Data Sources
Epidemiology
Claims data
Expert panels
Economic and quality of life studies
Clinical trials for drugs, devices, diagnostics
Published literature
Primary market research
Disease models, disease maps,standards of care
Project impact of disease-specific process changes and utilization and cost control measurements
Basis for capitation and risk sharing
Validate
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Core Components Processes of Outcomes Measurement
1. Define data requirements- Determine what sorts of outcomes need to be measured- Determine what measurement tools should be used
2. Obtain the data- Define data collection protocol- Implement data collection protocol
3. Manage the data- Create database- Enter data into database- Assure quality of data
4. Analyze the data- Analyze data quality and completeness- Determine method for scoring responses to outcome indicator- Perform risk adjustment- Perform outcome analysis
5. Report results- Prepare written summary of results- Present results to key customers
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Disease Management in NHG
We have formed 8 teams that will focus on:
- Congestive Heart Failure / Acute Myocardial Infarction
- Asthma / COAD
- Stroke
- Diabetes Mellitus
- Hypertension / Hyperlipidaemia
- Specific cancers (eg breast, lung)
Development of clinical databases / disease registries
Primary healthcare enhanced care programmes
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Disease Management – operational considerations
• Preliminary data – epidemiology and patient profiles, DRG data, financial data, etc
• Multidisciplinary workgroups to draft plans – develop shared care evidence-based protocols or pathways, case management practices and use of care coordination tools (eg telephone reminders, web-based interactive reminders)
• Focus on prevention and self management – establishment of a vascular disease risk factor prevention workgroup and using IT tools to promote patient adherence and self monitoring
• Standardising clinical pathways between institutions• Post discharge follow up and linkages with the community• Continuing care between the family physician, case manager and
hospital specialist
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Disease Management – unresolved issues
• Funding for such programmes in an output-based, non-capitated environment
• Incentives for patients to do better for themselves
• Operational running costs for disease registries
• Incorporating quality of life measures into real and practical indicators which give providers a better understanding of the impact of interventions on health status
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Critical Success Factors
• Select key clinician champions as leaders• Provide adequate resources and case managers to support the
programme• Appropriate funding incentives to be built into the system (eg
capitation in the USA)• Using information technology to harness clinical information
sharing and seamlessness at the back-end of care delivery• Team-based approach• Disease registries
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Useful Contacts• Disease Management Association of
America (DMAA) – www.dmaa.org
• National Healthcare Group – www.nhg.com.sg
• HCFA website
• Managed care websites
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Thank you
See you at Asia’s First Disease Management Conference
25-26 May 2001 Sheraton Towers Hotel, Singapore