Optimizing Chronic Disease Management

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Optimizing Chronic Disease Management

• Leslie Worth
• Manager, Chronic Disease Management
• Saskatoon Health Region
• February 1, 2007

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Outline

• Using a Chronic Disease Management Approach
• Wagners Chronic Care Model
• SHR Objectives and CDM Structure
• CDM Program Development
• Next Steps

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Using a Chronic Disease Management (CDM) Approach

• A new approach to healthcare
• Team-based (the right person doing the right job)
• Optimize care and patient-centered outcomes
• Promotes self-management

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The Problem

• 10 of the population uses up to 60 of health
  care costs
• Multiple chronic conditions
• Not age-specific
• Many readmissions with predictable and
  preventable complications

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The Challenge

• For our health care system to manage chronic
  conditions as effectively as it manages acute
  situations

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Wagners Chronic Care Model

• Delivery System Design
• System Redesign
• Multidisciplinary teams
• Case management
• Decision Support
• Evidence-based practice
• Standardized guidelines

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Wagners Chronic Care Model

• Self-management Support
• Education Live Well
• Goal setting
• Action plans
• Clinical Information System
• Patient Tracking/flow sheets
• Electronic medical record
• Web-based database
• Quality measurement

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Wagners Chronic Care Model

• The Community
• Strong link with NGO, Industry, Community Clinic,
  Aboriginal Groups, Business Community, Health
  Quality Council, COS, U of S,
• Satellite program sites
• Health System Organization
• Link with Primary Health
• Link with Public Health
• Link with Homecare
• CDM Operations Committee

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SHR Objectives

• To integrate existing CDM services, and develop
  new programs and partnerships
• To involve family physicians (and others) in
  effective client centered, team-based care
• To establish lead provincial programs and
  services (urban and rural), including key
  under-serviced areas
• To objectively evaluate patient care and outcomes
• To develop resources for patients, families and
  heath professionals

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Outcomes We Expect

• Improved, optimized and coordinated patient care
  and management
• Enhanced linkages, communication and partnerships
• Cost Avoidance decreased hospital admissions,
  emergency room visits, unscheduled urgent care
  visits, surgical interventions

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Support from Senior Leaders

• COMPONENTS OF SHR STRATEGIC PLAN
• Enhanced chronic disease management programming
• Enhanced primary health programming
• Regional integration

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Saskatoon Health Region Linkages and
Partnerships
Primary Health Teams - central, visiting -
satellite programs (diabetes)

• Chronic disease prevention
• - physical activity
• - obesity
• - smoking
• Mental Health and
• well-being
• Addictions

Diabetes Respiratory Cardiovascular
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SHR CDM Reporting Structure
Senior Leadership
Primary Prevention and Health Promotion
Primary Health
CDM Executive Committee CDM Operations Committee
Action Teams
Diabetes Reference Chronic Lung
Disease CVD Working
Live Well Group
Working Group
Group Group

Quality Improvement
Performance / Outcomes Measurement
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Program Pillars of CDM

• Group Exercise and Rehabilitation
• Disease-Specific Management
• Patient Self-Management Skills

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Group Exercise and Rehabilitation

• Community-based supervised exercise programming
• Group education
• Socialization

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Group Exercise and Rehabilitation
Patient Self-Management Skills

• Community-based supervised exercise programming
• Group education
• Socialization

• Peer-led group classes and support
• Enhanced self-management skills and
  decision-making

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Group Exercise and Rehabilitation
Disease-Specific Management
Patient Self-Management Skills

• Peer-led group classes and support
• Enhanced self-management skills and
  decision-making

• Community-based supervised exercise programming
• Group education
• Socialization

• Nurse-Clinician working with the patient, their
  Family Physician and/or Specialist
• Evidence-based optimal care delivery

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CDM Programs and Services

• First Step Program
• Cardiac Rehabilitation Program
• Diabetes Education Program
• Live Well with Chronic Conditions
• Tobacco Reduction
• COPD Inspire Program
• Pulmonary Rehabilitation Program
• Cystic Fibrosis Program
• Sleep Disorders Centre
• Sleep Well Program

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CDM Programs and Services

• Hepatitis Program
• Central Saskatchewan Immunodeficiency Program
• Bosom Buddies
• Retreads
• Chronic Pain Clinic
• In Motion
• Road to Well Being
• SWEETheart Program

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SHR CDM Planning

• 3 Disease Populations Identified
• COPD
• Diabetes
• Cardiovascular Disease

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CDM Program vs Hospitalizations

• Program Cost ( per patient per year)
• Building Resistance to Diabetes 80 - 120
  
• Ethno-cultural screening 25 - 60
• First Step Program 350
• Hospitalization ( per patient per day)
• ICU Bed 2000
• Medicine Ward Bed 350

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Why Start with COPD?

• Limited attention to COPD in the past very few
  COPD programs
• 4th leading cause of death, disability and
  hospitalization
• Deaths in North America twice as high as from
  Diabetes
• COPD rates 3-5 x higher in Aboriginal
  populations
• In the Saskatoon Health Region, COPD highest
  readmission rate of all chronic medical
  conditions

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Initiating a COPD Program

• Assess need
• Collect best evidence
• Obtain support from senior leaders
• Assess budget and funding needs
• Determine outcome measurements
• Develop meaningful partnerships
• Start small
• Evaluate frequently

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Pauwels RA, et al. Lancet 2004 364616-620
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Jamal A, et al. JAMA 2005 2941255-1259
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Comprehensive COPD Management
Bourbeau J, et al. Arch Int Med 2003,
163585-91 Can Respir J 2004 11(Suppl B) 7B-59B
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The SHR Live Well COPD Program

• ORIGINAL PILOT PROJECT (2004)
• Grant from Health Quality Council (30K)
• Hired 0.5 FTE Nurse Clinician for term position
  (Summer 04 Mar 05)
• Pulled charts of COPD patients with readmissions
  for exacerbations (1 site)
• Permission from patient and family physician
• Assessment, education, action plan
• Referral to existing pulmonary rehab program
• Evaluation (Quality Focus)

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The SHR Live Well COPD Program

• GOALS
• To optimize management and improve the quality of
  life for COPD patients and their families
• To promote an interdisciplinary team approach for
  patient-centered self-management

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The SHR Live Well COPD Program

• OBJECTIVES
• To integrate existing programs, develop new
  programs and build capacity
• To involve family physicians, home care staff and
  others in team-based care

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The SHR Live Well COPD Program

• OBJECTIVES
• To develop services in urban and rural areas,
  including key under-serviced areas
• To objectively evaluate patient care and outcomes

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The SHR Live Well COPD Program

• PROCESS
• Inpatient identification or referral initiated
• Eligibility review
• Nurse Clinician facilitates plan of action in
  collaboration with family physician/specialist
• Assessment, education and self-management
  sessions
• Referral to Pulmonary Rehabilitation Program
• Follow-up
• Evaluation

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Pulmonary Rehab Program

• Increased Pulmonary Rehabilitation capacity
• home site (Field House) is full
• established 1st satellite in part of Saskatoon
  with the highest incidence of chronic diseases (
  in mall)
• assisted with establishing program in Regina
• additional satellites programs rolled out
  (Humboldt, Prince Albert) and others planned
  (other malls, Saskatoon core, Yorkton, Moose Jaw)

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Determine Outcome MeasuresSHR COPD Readmission
Rates
Excludes Pediatric cases age 16 and
under. LOSLength of Stay (days) ALOS Average
length of Stay (days) Discharges most
responsible diagnosis for hospital stay SHIPS
June 2005
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Comprehensive COPD Management

• Benefits persist over 2 years (Gadoury MA, et
  al. Eur Resp J 2005 26853-857)
• A caseload of 50 patients equals cost-savings
  (program vs usual care) of 2,149 2,300 /year
• Concluded that a caseload of 70 patients was
  achievable and reasonable (additional savings of
  310 /year)
• Reduced hospitalizations, reduced exacerbations,
  and reduced healthcare costs

Bourbeau J, et al. Chest 2006 in press
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What Have We Seen So Far?

• Reduced COPD re-admissions by 30 ( until 2005,
  but by 17 with last weeks 2006 data)
• Re-admission rates of 1 1.9 2.1 (2004)
  changed to 1 1.6 1.2 (2006)
• Decreased ICU days by 44 (2006), with a cost
  savings in 2005 of 261,333, and in 2006 of
  308,333.

Saskatoon Health Region Statistics, 2006
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Community Diabetes Outreach Program
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Shared Vision

• Build community capacity
• Community consultation and participation
• Coordinate and share resources
• Create supportive environments
• Integrate peer leadership
• Relationships are key

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Overall Goal

• To develop a model for the primary prevention and
  management of type 2 diabetes targeted toward the
  Aboriginal community

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Short-Term Goal
To increase access to diabetes services for the
populations living in the core neighborhoods
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Objectives

• Partnership and Promotion
• Increase Community Capacity
• Develop Sustainable Programs

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Primary Prevention

• Develop screening education program for high
  risk individuals and families
• Connect participants with appropriate programs
  and services
• Provide follow-up

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Secondary Prevention

• All About Diabetes Program
• Culturally sensitive programs
• Clinical / education/ physical activity
• Support and self-management
• Peer lead support sessions
• Collective kitchen programs/Good food box

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How are we doing?

• Partnership between SHR SCC
• Proposal for joint funding SHR/SCC accepted
• Diabetes Community Outreach Worker hired (.5 FTE
  )
• Management team established
• Planning sessions and Evaluation Plan

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How are we doing?

• Proposal to SHR Community Wellness Grant approved
  
• Fitness Food Fun Program began June 06
• MOUAIPP Proposal approved
• Diabetes Community Outreach Coordinator hired Dec
  06

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Next Steps

• Hire additional staff
• Formalize role of Diabetes Community Outreach
  staff
• Formalize activity component
• Data Collection and Evaluation
• Ongoing management meetings
• In consultation with partners, develop peer
  leadership program

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Next Steps

• Build a Diabetes Advisory body
• Formalize existing partnerships
• Engage new partners
• Seek sustainable funding

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The Value of Partnerships

• Share costs for program start-up
• Share human resources
• Space donation
• Equipment and supply donation
• Medical advisement
• Enhanced program promotion
• Enhanced community relationships

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SHR Partnerships

• Portfolios Within Saskatoon Health Region
• Primary Health, Public Health - Prevention
  Promotion, Homecare, SHIPS, in motion
• Health Regions Within Saskatchewan
• Health Regions in Other Provinces
• Calgary Health Region, Capital Health Region
• Health Quality Council

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SHR Community Partnerships

• Non Government Organizations
• Aboriginal Groups
• Family Physicians
• Pharmaceutical Companies
• Industry

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SHR Partnerships (contd)

• Saskatoon Community Clinic
• White Buffalo Youth Lodge
• SWITCH
• Local Shopping Mall
• City of Saskatoon
• Saskatchewan Health
• Health Canada
• University of Saskatchewan

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Live Well Program

• Cost-effective, integrated provincial program -
  centralized coordination with both urban and
  rural delivery
• Strategic, focused design and delivery
• the right person doing the right job
• Build the relationship between the patient and
  family and their family physician
• Interventions that are not evidenced-based will
  not be utilized or promoted

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Live Well Program

• Ongoing outcome evaluation of both patient and
  program is necessary
• An electronic data management system is used for
  patient care, and also to facilitate
  communication, coordination and evaluation
• The program philosophy, design and delivery is
  common for many chronic medical conditions The
  model works and borrows the learning's of others

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How Are We Doing?

• Assessment of Chronic Illness Care Using CDM
  Assessment Tool (Wagners Model)
• - Community Linkages - Self-management
  support
• - Decision Support - Delivery System
  Design
• - Information Systems - Organization of Care
• March 2002 SDH score 1.8 (limited support for
  CDM)
• June 2003 SHR score 4.9 (basic support for
  CDM)
• March 2006 SHR score 6.0 (reasonably good
  support for
• CDM)
• Still room to improve (top score 11)

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Assessment of Chronic Illness Care SHR (March
2006)
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Where Do We Want to Go?Next Steps

• Build capacity (, human resources,
  infrastructure)
• Continuous evaluation and monitoring of current
  initiatives
• Further expansion into diabetes, cardiac, renal,
  and sleep disorders programs
• Strengthen existing and build new partnerships
• Ongoing advocacy, education and messaging about
  benefits of CDM

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Optimizing Chronic Disease Management in the
Saskatoon Health Region will have numerous short
and long term benefits and is the right thing to
do
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SHR CDM Executive Committee Members
Donna Bleakney Director, CDM Dr. Darcy
Marciniuk Medical Director, CDM Sheila
Achilles Director, Primary Health Leslie Worth
Manager, CDM 306-966-8298 live-well_at_saskatoo
nhealthregion.ca
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Questions?