Chronic disease in PHC

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Chronic disease in PHC
Mark Harris UNSW Research Centre for Primary
Health and Equity
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Chronic Disease

• Conditions with gradual onset and lasting more
  than 6 months
• Often develop over the persons lifetime
• Tend to be progressive and/or lead to
  complications
• Multiple factors cause them and may be symptom
  free early on (insidious onset)

• Cardiovascular disease
• Cancer
• Mental health problems
• Diabetes
• Chronic respiratory disease
• Chronic muskulo-skeletal conditions (OA, RA etc)
• Nervous system diseases
• Renal disease

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Burden of disease ( of total DALYs) AIHW 2000
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Death rates for coronary heart disease and
stroke, 195098
Rate per 100,000
Source AIHW National Mortality Database
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Health expenditure on chronic diseases, by area
of expenditure, 2000-01
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NCD Determinants

• BEHAVIORAL
• Tobacco
• Diet
• Physical Activity
• Alcohol
• Sex, Repro Health
• ENVIRONMENTAL
• Socio-cultural
• Policy
• Economic
• Physical
• NON-MODIFIABLE
• Age, Sex, Genes

• END-POINTS
• Ischemic Heart Dis.
• Stroke
• Peripheral Vasc. Dis.
• Cancer
• Mental Illness (Depression, Epilepsy, Suicide)

• INTERMEDIATE RISK FACTORS
• Hypertension
• Blood lipids
• Diabetes
• Obesity
• HPV, HBV
• Trauma

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Change in CV risk factors in Australia
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Risk Factors by Socioeconomic status Australians
aged 18 and over (AIHW)
Obesity 1995 and 2001
Number of Risk Factors 2001
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Chronic disease and behavioural risk factors in
general practice ( of patients) BEACH 2003
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Rationalisation for greater role for PHC in
chronic disease management

• Changing focus
• shift from acute to chronic care
• Promoting health of communities as well as
  individuals
• prevention as well as treatment
• Shift in location from hospital to community care

Failure of Primary Care Leads to Unnecessary
Hospitalizations
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Comprehensive care for chronic conditions in
primary care

• Clearly defined points for access to, and
  transition within, health services
• Evidence based prevention and case finding,
• Continuing care including
• Self management education
• Assessment of needs, control, severity, and
  complications
• Negotiated goals
• Planned and coordinated care across providers

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Key components of access to PHC for chronic
disease

• Information about availability
• Clearly stated and consistent criteria for access
  to services
• Available locally
• Available after-hours
• Available with short waiting times
• Appropriateness (length of consultation, range of
  services)
• Cost to consumer
• Acceptability to consumer

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Population Approaches to chronic disease
prevention

• Reductions in smoking advertising and
  availability, increase cost and promote
  cessation,
• Promotion of moderate alcohol intake and road
  safety,
• Promotion of healthy choices to reduce saturated
  fat and refined CHO and increase fruit and
  vegetable consumption, food labeling and
  advertising
• Raising awareness of physical activity, point of
  decision prompts in workplace,

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Per-capita consumption of tobacco and death rates
for cancer 1945-1990
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Risk groups
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High Risk Approach SNAP
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Continuing Care for Chronic Disease 3
Overlapping Dimensions of Care
Patient Self Management
Systematic Planned Care
Coordination continuity
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1. Self Management

• Support the role of patients in managing their
  chronic conditions through
• Knowing their condition and various treatment
  options
• Negotiating a plan of care and adhering to the
  plan
• Engaging in behaviour that protect and promote
  health
• Monitoring and managing the symptoms and signs of
  the condition and
• Managing the impact of the condition on physical
  functioning, emotions and interpersonal
  relationships.

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2. Systematic Planned Care

• Systematic assessment
• Evidence based interventions
• Monitoring
• Referral according to criteria
• Continuity and Follow up

Diabetes Care in General Practice 1999 NDDP
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3. Collaborative care
Wagner describes patient care teams as comprising
diverse healthcare professionals who communicate
regularly about the care of a defined group of
patients and participate in that care on a
continuing basisi. i Wagner EH. The role of
patient care teams in chronic disease management.
BMJ 2000 320 569-572.
Shared care team
Multidisciplinary team
Individual provider and patient
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Shared care

• Shared care involves
• systems to create linkages between services or
  organisations
• common goals, objectives and guidelines
• information and communication systems
• education and quality assurance and
• care planning.
• Hampson, JR, Roberts RI, Morgan DA. Shared care
  a review of the literature. Family Practice
  1996 13264-279.

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Complimentary roles of Community Health and
General Practice in comprehensive care for
people with chronic disease

• Community health
• Multidisciplinary, used to working in teams
• works with both individuals and populations
  including marginalised and at risk groups
• Capacity provide longer more intensive
  interventions support self management

• General practice
• Reaches a larger proportion of population
• Continuity of care across multiple conditions
• Evidence based generalist medical care
• Access to services under Medicare

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Capacities underpinning MD teamwork

• Risk factors
• Assessment
• Register/recall
• Care planning

Quality of Evidence Based Care
Linkages With other services
Multidisciplinary Teamroles IT/IM Finance
Patient Assessed Care

• Access
• Continuity
• Satisfaction

Team culture
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Use of information

• For shared patient care
• Referral
• Follow up
• Recall or reminders

• For quality improvement, monitoring and
  evaluation
• Up so that it can analysed and so that the whole
  system can be planned and evaluated.
• Down to remind doctors and patients that some
  processes have been missed and to provide audit
  reports so that doctors can improve their quality
  of care

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Sharing information across services

• Characteristics
• Easy to record or collect
• Relevant to care being provided
• Accurate
• Immediately available (no delay)

• Models
• Patient held
• Sent via email, fax or post
• Registers/web records

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PHC workforce development

• There is a need to ensure that the PHC system has
  sufficient capacity to change. This will
  include-
• Adequacy of the workforce supply and sufficient
  flexibility to allow role substitution.
• Education of the workforce not only at provider
  level but at health organisation management
  levels.
• Appropriateness of performance measures and
  monitoring at all levels
• Sufficient evidence to inform practice at all
  levels

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Funding

• Funding and incentives to support
• disease prevention
• systematic patient assessment
• self management education
• care planning and active follow up over time
• referral to level 2 primary health care (eg
  allied health)
• alternatives to hospitalisation or
  institutionalisation
• capacity building teamwork, IMIT, shared care

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Outcomes of PHC management of patients with
chronic disease

• Consumers
• Increased reach of disadvantaged groups Reduced
  errors
• clients with a comprehensive multidisciplinary
  care
• self management program
• Improved access to other services.

• Health System
• Appropriate referral and health service use
• Reduce avoidable ambulatory sensitive admissions
  and ED presentations

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Some Challenges opportunities

• The current focus on behaviour rather than social
  and economic determinants
• New chronic disease and allied health Medicare
  items
• Reorganization of Community Health within NSW
  Health
• New performance indicators for Divisions
• Development of national PIs for other primary
  health care services (NHPC)
• Disease prevention programs (Colorectal,
  Diabetes)

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The future

• Increasing focus on chronic disease prevention
  SNAP, diabetes and CVD and early detection
  based around primary health care teams
• Increasing focus on long term care in the
  community (PHC and aged care)
• Integration of general practice and State
  community health services management of chronic
  disease
• Increasing inequity of access to high cost care
  for chronic diseases