Practice management in co-morbid patients

Jaime Correia de Sousa, MD, MPH

Horizonte Family Health UnitMatosinhos Health Centre - Portugal

Health Sciences School (ECS) University of Minho, Braga - Portugal

Objective

At the end of this session the participants will: Know why we need a new model of care for

co-morbid problems Value primary health care orientation in the

care for chronic patients Demonstrate the importance of clinical

information systems in the management of co-morbidity

Recognise the need for a chronic care model Value an approach to teaching and learning

about co-morbidity management

Introduction

Most patients with chronic illnesses do not have a single, predominant condition.

Most have co-morbidity, the simultaneous presence of multiple chronic conditions.

Patients seek care for all of their co-morbidities, not just for a solitary, defining, major condition.

Grumbach, 2003

Introduction

The majority of visits for care of both an indicator condition and its associated co-morbidities are made to primary care physicians.

What is needed is a model of care that addresses the whole person and integrates care for the person’s entire constellation of co-morbidities.

Grumbach, 2003

Case Study

• Mrs B, head teacher of a primary school, 52 years old, overweight, has diabetes mellitus

• Doesn’t exercise; easily tired with small efforts; has a bad knee that keeps bothering her. The cholesterol level is high.

• Mrs B blood pressure is regularly checked and is within normal values.

• Mrs B has smoked all her adult life

Case Study

• Mrs B came to see her FP with a bad attack of bronchitis and was told by her doctor that she suspected she had asthma.

• The doctor prescribed an AB for the bronchitis and an inhaler for the asthma.

• Mrs B disagreed with her diagnosis of asthma and so took the antibiotics only.

• Within about 2 weeks she was much better and felt vindicated in her opinion about the asthma.

Case Study

• She continued to have difficulty climbing the stairs to the third floor at the top of the school but she put her difficulty down to the ravages of age, overweight and cigarettes.

• Her peak flow when measured by the doctor in the surgery was 240 litres per minute. It should have been 480 litres per minute.

Case Study

In 5 m discuss in pairs:

1. Identify the major co-morbid health problems in this patient

2. The impact of a new diagnostic label and models of illness

Case Study

To discuss later in the group:• The most important tasks

required to promote a better care for this patient

• Design a care package for this patient, considering the aims of care and the resources needed

A new model of care?

Basic Questions Who should be involved

in care? What are our aims? How should we

organise care?

Basic Questions

What is the prevalence of co-morbidity among patients in family medicine?

How does this prevalence differ by the sex and age of the patient?

How does the prevalence differ between different conditions, particularly acute and chronic conditions?

Who should be involved in care?

PatientPatient

Patient’s familyPatient’s family

PHC TeamPHC TeamFamily physicians

Nurses Receptionists

HospitalHospital doctors and

nurses

CommunityCommunityPharmacists

PhysiotherapistsPsychologists Social workers

etc

What are our aims?

Provide the best available care Consider patient’s choices Realistic aims with available logistics (staff,

premises, funding) Adequate management of the health systems’

resources Prevention of health inequities Reduce the economic burden of illness in the

family

How should we organize care?

Traditional Chronic Disease Specific Approach

Chronic Care Model

Components of the Chronic Care Model

Community Organisation of health care Support self management Design of delivery system Decision support Clinical information systems

Lewis & Dixon, 2004

Components of the Chronic Care Model

Community Mobilise community resources to meet

needs of patients

Organisation of health care Create a culture, organisation, and

mechanisms that promote safe, high quality care

Lewis & Dixon, 2004

Components of the Chronic Care Model

Support self management Empower and prepare patients to

manage their health and health care

Design of delivery system Assure the delivery of effective,

efficient clinical care and self management support

Lewis & Dixon, 2004

Components of the Chronic Care Model

Decision support Promote clinical care that is consistent

with scientific evidence and patient preferences

Clinical information systems Organise patient and population data to

facilitate efficient and effective care

Lewis & Dixon, 2004

Primary health care orientation

Reconciling the health needs of individual patients and the health needs of the community

Community or list based, personally and family oriented

Health promotion, prevention, cure, care and palliation and rehabilitation.

Covering the full range of health conditions Co-ordination of care with other professionals Pro-active

Patient centred model

1. Exploring both the disease and the illness experience

2. Understanding the whole person 3. Finding common ground regarding

management4. Incorporating prevention and health

promotion5. Enhancing the Doctor-Patient relationship6. Being realistic

Levenstein (1984)

Patient centred model

The importance of clinical information systems

Appointments systems Enabling call and recall programmes Repeat prescribing Drug alerts (interactions, contraindications,

secondary effects) Decision support / expert-system Supporting audit

Model of care for patients with co-morbid conditions

Chronic care model

Patient centred modelPrimary health

care orientation

Clinical Information

System

Model of care for patients with co-morbid conditions

Chronic care model

Primary health care orientation

Patient centred model

Clinical Information

System

THE TRANSFORMATION

Care is Proactive

Care delivered by a health care team

Care integrated across time, place and conditions

Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology

Self-management support a responsibility and integral part of the delivery system

Chronic Care Model

Source: KPCMI

Complete Forms

Deal withAcute Attackof Disease

Counsel re: Lifestyle ChangesReview

LabsAccess

Social/Other Services

Reassure

Diagnose

General Referral

Review/Adjust Rx and Tx Routine

Preventive Care

Modify and/or Negotiate Care

Plans

Review History

Review Care Plan

Talk with Family

Reinforce Positive Health

Behaviours

Traditional Model

SICKNESS CARE MODEL (Current Approach - Physician Centric)

Consultation 10 minutes

So, how do we make this paradigm shift?

Start with better data extraction and information analysis to inform decisions

Implement case management for patients with highest burdens of disease

Implement guidelines for managing diseases and consider care co-ordination

Support self management and self care Measure progress and achievement; and

adjust process when necessary

Conclusions

1. Chronic illnesses are becoming the main activity of family physicians

2. Chronic diseases don’t exist isolated3. Frequently, patients have more than

one condition4. A generalist approach is necessary5. Shared care is important… but6. We need a family practice based

Chronic Care Model

Conclusion