Chronic Disease: The Challenge of Implementation

Chronic Disease: The Challenge of Implementation
Rafael Bengoa,
Basque Government.
Spain
…here too…
Evolution of diabetes and cardiovascular disease in the Basque Country%
1992 1997 2002 2007
4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0
Going Fast …
1990 1995 2001
No Data <4% 4%-6% 6%-8% 8%-10% >10%
Mokdad AH, et al. JAMA 282:16, 1999, and 286:10, 2001.

SAME PATTERN AS OTHER COUNTRIES …
Tres o más
8,6 %
Ninguno
23,5 %
Dos 28,9 %
39,1 % Uno
Fuente: ESCAV 2007

Medical consultations/capita. Europe. 2003
9.5
10
5.9
2
2.5
0
Gre Sue Por Fin UK Pb Ita Lux Irl Aus Fra Ale Din Bel Esp
European Countries
Ecosalud. OCDE 2005.
The drivers….
! Prevention !
Medical Consultations / Capita. European Countries
Fragmentation
80% interventions 77% Expenditure
…3 our of 4 deaths in 2020 2/3 of growth in expenditure

Intervene across the Continuum of Care
Health Secondary Prevention & Palliative

Promotion Disease Management Care
Active Severe
$ Healthy/Low Risk At Risk High Risk Diseas Diseas
e e
Primary Prevention Complex Case

Management
Age
0 20 40 60 80
$?
How can (chronic care) performance be enhanced
Some Frameworks ……..
Gestión
de casos
complejos Sistema de Salud
Comunidad Organizacion de atencion
Gestión de Recursos y sanitaria
la Atención Politicas Auto Diseño Apoyo a Sistemas de
gestión sistema la información
prestación decision clinica
Apoyo a la auto
gestión
Paciente Interacciones Equipo de

Estratificación del riesgo salud
Informado Productivas
Activado Proactivo
Resultados Clínicos y Funcionales

Gestión
de casos
complejos
Gestión de
la Atención
Apoyo a la auto
gestión
Estratificación del riesgo

How can (chronic care) performance be enhanced
From Improving Chronic Illness Care

Ed Wagner, MD, Group Health Cooperative of Puget Sound
UC Berkeley Study
Use of Care Management Processes by Type of Chronic Condition
Type of CMPs Diabetes Asthma CHF Depression Each of 4

(n = 523)+ (n = 522) (n = 526) (n = 497) Chronic Illness
It Treats
(n = 491)
Patient list or registry 70.2% 62.4% 58.5% 40.8% 39.1%
Provide patient educators 73.9% 53.8% 53.6% 35.4% 30.5%
Physician feedback on quality 66.1% 56.1% 50.8% 32.8% 30.9%
Nurse care managers 54.7% 42.7% 47.5% 25.1% 23.8%
Patient reminders 51.4% 35.2% 35.0% 19.7% 19.1%
Point-of-care reminders 51.2% 36.4% 33.1% 22.9% 19.5%
No. (%) using all 6 CMPs 21.6% 10.5% 10.1% 4.4% -
No. (%) using all 24 CMPs - - - - 3.7%
Mean CMP Use (out of 6) 3.7 2.9 2.8 1.8 -
Mean CMP Use (out of 24) - - - - 11.1
Source: D. Rittenhouse et al., “Improving Chronic Illness Care: Findings From National
Study of Care Management Processes in Large Physician Practices,” 2009, Under Review.
Our system needs changes
No risk stratification…
No case nurses…
No routine clinical reminders…
No continuum of care…
No activated patient…
No regular telemonitoring……
Stroke-related Hospitalization ST Elevated MIs in No. Cal.
Rates in No. Cal. 1998-2007
2,0
1998-2007
2,0
1,8
Age and sex adjusted rate per 1,000

Age and sex adjusted rate per 1,000
1,9
1,6
1,8
1,7 1,4
1,6
1,2
1,5
1,0
1,4
1,3
0,8
1,2
0,6
1,1
1,0 0,4
98 99 00 01 02 03 04 05 06 07 98 99 00 01 02 03 04 05 06 07
19 19 20 20 20 20 20 20 20 20 19 19 20 20 20 20 20 20 20 20
KP Northern California ALL program, PHASE, results. 17

VA Continues to Exceed HEDIS in 2008
INDICATOR VA 2008 VA 2007 Commercial Medicare Medicaid

2007 2007 2007
Breast cancer screening 87% 86% 69% 67% 50%
Cervical cancer screening 92% 91% 82% n/a 65%
Colorectal cancer screening 79% 78% 56% 50% n/a
LDL Cholesterol < 100 after AMI, PTCA,

66% 62% 59% 56% 38%
CABG
Diabetes: DM control HbA1c < 9.0% 84% 84% 71% 71% 52%
Diabetes: LDL-C<100 68% 64% 44% 47% 31%
Diabetes: Eye Exam 86% 85% 55% 63% 50%
Diabetes: Renal Exam 93% 91% 81% 86% 74%
Diabetes: BP < 140/90 78% 77% 64% 59% 56%
Hypertension: BP < 140/90 75% 76% 62% 58% 53%
Smoking Cessation Counseling (3) 89% 83% 76% n/a 70%
Smoking : Medications offered(3) 84% n/a 51% n/a 39%
Smoking: Referral/strategies (3) 92% n/a 48% n/a 39%
Immunizations: influenza 84% 72% 49% 72%
Immunizations: pneumococcal 94% 90% n/a 67%

Moving 14 Strategic Projects
Visión
Population Prevention and Patient Continuum of Personalized

focus promotion autonomy care interventions
Population Prevention and Expert patient Unified health Multichannel
stratification promotion records service center
interventions
Integrated E-Prescription
clinical care
Telemonitoring
New nurse roles experiences
Socio-health Chronic care

continuum infrastructures
Financing & Chronic care

commisioning innovation center
Clinical innovation
Strategic Projects: Integrated Approach
3
2 Prevención y Promoción Autocuidado
Prevención de aparición y Experiencias en las 4 Historia Clínica
1 Estratificación
desarrollo de principales enfermedades unificada
Estratificación operativa crónicas, potenciando la 5 Atención clínica
enfermedades crónicas Implantación
de la población vasca de adherencia y el uso integrada
(De_Plan, prevención universal a finales
forma sistematizada y apropiado de los recursos Un tercio de las
tabáquica) de 2011
periódica desde 2011 organizaciones a 2013,
con procesos integrados
14
Innovación desde los
6
profesionales Generación de Competencias Avanzadas
15-25 proyectos de innovación Enfermería
al año y extensión de los que Formar a 300 enfermeras
demuestren resultados (~90%) en los nuevos roles hasta
2013
13 Centro Investigación 7
Cronicidad Colaboración sociosanitaria
Ser un referente internacional 4 municipios con
en el conocimiento sobre funcionamiento integrado, 1
enfermedades crónicas hospital con plan de altas con
prevención de dependencia, 1
12 Modelo hospitales subagudos unidad de ortogeriatría
Implantación del modelo en

hospitales de media estancia y 8 Financiación y Contratación
creación de nuevo hospital de
Implantación plena de un
crónicos en Álava
9 sistema de asignación
11 Centro Servicios Multicanal financiera
Experiencias de 10 Receta electrónica territorial ajustada
telemonitorización Despliegue en Euskadi de
Implantación efectiva del por riesgo
Monitorización a distancia del 1% todos los servicios para
sistema de receta electrónica
de enfermos crónicos severos mediados de 2013
en todo Euskadi en 2012 –
(~22.500)
2013
Increased use of Technologies : Smart Home
Remember
your
medicine
WE WILL PROBABLY ALL END UP WITH SOME SORT OF
STRUCTURED PATIENT EDUCATION : BOTH DIRECT AND
REMOTE
PATIENT EDUCATION REMOTE PATIENT

EDUCATION
With some sort of case manager ( Nurse )
Nurses who act a case

Gestión
n
de casos
complejos
managers for patients with Gestión de

la Atención
complex conditions. Apoyo a la auto

gestión
Estratificación del riesgo
n Their function will be to

evaluate their physical and
social needs and coordinate
their care.
The payoff
6,000,000
5,000,000 52.6 M
4,000,000
3M
3,000,000
20.8 M
Registered members
2,000,000
Lab test results
viewed online
1,000,000 E-mails sent to
providers
Visits to past visit

0 information
07
08
07
07
07
08
08
08
09
09
09
09
Online prescription
1Q
3Q
2Q
3Q
4Q
1Q
2Q
4Q
1Q
2Q
3Q
4Q
refills
Source KP
Change Process:
Too Mechanic ??
Evidence increasing around a few things…
n Different diseases , similar needs and similar solutions
n It is a cultural change: It is deep. It is about the way

we work and behaviour
n To pull this off you need patients and staff on board.
n It is therefore less about structural moves than about

staff engagement
WHERE IS THE CHALLENGE FOR POLICY MAKERS?
Strategy
Systems Structure
Skills
Values Leadership
STAFF
Bottom up
No scale
No alignment
Top down
Not accepted
Not adapted
Abandon a Hierarquical Culture
- Apparent stability …
- Rules y regulations …
- Simplistic for organizations and problems of today
- Politicized
Build a “Development” Culture

- Accept complexity and diversity
- Promote Local experimentation/research
- Provide “space” and local autonomy
- Work with pioneers and early adopters
- Better balance top down and bottom up

Some Signals for all…
n Evidence growing around a few things
n Policy makers need to bring this up to first division
n Therefore need to intervene in an aligned way across

macro, meso and micro levels
n The power of results. Evidence growing but scalability

still an issue
Alignment !
+ Macro
+++ Meso
++++ Micro

Chronic Disease: The Challenge of Implementation

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Chronic Disease: The Challenge of Implementation

Evolution of diabetes and cardiovascular disease in the Basque Country%

1992 1997 2002 2007

1990 1995 2001

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Mokdad AH, et al. JAMA 282:16, 1999, and 286:10, 2001.

Fuente: ESCAV 2007

…3 our of 4 deaths in 2020 2/3 of growth in expenditure

Health Secondary Prevention & Palliative

Primary Prevention Complex Case

Some Frameworks ……..

Paciente Interacciones Equipo de

Resultados Clínicos y Funcionales

Estratificación del riesgo

From Improving Chronic Illness Care

Type of CMPs Diabetes Asthma CHF Depression Each of 4

Provide patient educators 73.9% 53.8% 53.6% 35.4% 30.5%

Physician feedback on quality 66.1% 56.1% 50.8% 32.8% 30.9%

Nurse care managers 54.7% 42.7% 47.5% 25.1% 23.8%

Patient reminders 51.4% 35.2% 35.0% 19.7% 19.1%

Point-of-care reminders 51.2% 36.4% 33.1% 22.9% 19.5%

No. (%) using all 6 CMPs 21.6% 10.5% 10.1% 4.4% -

No. (%) using all 24 CMPs - - - - 3.7%

Mean CMP Use (out of 6) 3.7 2.9 2.8 1.8 -

Mean CMP Use (out of 24) - - - - 11.1

No routine clinical reminders…

Age and sex adjusted rate per 1,000

KP Northern California ALL program, PHASE, results. 17

INDICATOR VA 2008 VA 2007 Commercial Medicare Medicaid

Cervical cancer screening 92% 91% 82% n/a 65%

Colorectal cancer screening 79% 78% 56% 50% n/a

LDL Cholesterol < 100 after AMI, PTCA,

Diabetes: LDL-C<100 68% 64% 44% 47% 31%

Diabetes: Eye Exam 86% 85% 55% 63% 50%

Diabetes: Renal Exam 93% 91% 81% 86% 74%

Diabetes: BP < 140/90 78% 77% 64% 59% 56%

Hypertension: BP < 140/90 75% 76% 62% 58% 53%

Smoking Cessation Counseling (3) 89% 83% 76% n/a 70%

Smoking : Medications offered(3) 84% n/a 51% n/a 39%

Smoking: Referral/strategies (3) 92% n/a 48% n/a 39%

Immunizations: influenza 84% 72% 49% 72%

Immunizations: pneumococcal 94% 90% n/a 67%

Population Prevention and Patient Continuum of Personalized

Socio-health Chronic care

Financing & Chronic care

Implantación del modelo en

PATIENT EDUCATION REMOTE PATIENT

Nurses who act a case

managers for patients with Gestión de

complex conditions. Apoyo a la auto

Estratificación del riesgo

n Their function will be to

Visits to past visit

n Different diseases , similar needs and similar solutions

n It is a cultural change: It is deep. It is about the way

n To pull this off you need patients and staff on board.

n It is therefore less about structural moves than about

Build a “Development” Culture

- Promote Local experimentation/research

- Provide “space” and local autonomy

- Work with pioneers and early adopters

- Better balance top down and bottom up