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Chronic Disease: The Challenge of ImplementationChronic Disease: The Challenge of Implementation

Rafael Bengoa,Basque Government.Spain

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1992 1997 2002 2007

Evolution of diabetes and cardiovascular disease in the Basque Country%

4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0

here too

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Going Fast

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

1990 1995 2001

No Data 10%

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SAME PATTERN AS OTHER COUNTRIESSAME PATTERN AS OTHER COUNTRIES

Ninguno

Uno

Dos

Tres o ms

23,5 %

8,6 %

28,9 %

39,1 %

Ninguno

Uno

Dos

Tres o ms

23,5 %

8,6 %

28,9 %

39,1 %

Fuente: ESCAV 2007

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Medical consultations/capita. Europe. 2003Medical consultations/capita. Europe. 2003

0

2

4

6

8

10

Gre Sue P or Fin UK P b I ta Lux I rl Aus Fra Ale Din Bel Esp

5.95.92.52.5

9.59.5

European CountriesEuropean CountriesEcosalud. OCDE 2005.Ecosalud. OCDE 2005.

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The drivers.

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! Prevention !! Prevention !

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Medical Consultations / Capita. European CountriesMedical Consultations / Capita. European Countries

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FragmentationFragmentation

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80% interventions

3 our of 4 deaths in 2020

77% Expenditure

2/3 of growth in expenditure

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Intervene across the Continuum of CareIntervene across the Continuum of Care

$

0 40 8020 60 Age

Healthy/Low Risk At Risk High Risk

Active

Disease

Severe

Disease

HealthPromotion

Primary Prevention

Secondary Prevention &Disease Management

Complex CaseManagement

PalliativeCare

$ ?

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Estratificacin del riesgo

Gestinde casoscomplejos

Gestin dela Atencin

Apoyo a la autogestin



Gestin dela Atencin


Sistema de SaludOrganizacion de atencion

sanitaria

Auto

gestin

Diseo

sistemaprestacin

Apoyo a

ladecision

Sistemas de

informacinclinica

ComunidadRecursos yPoliticas

Equipo desalud

Proactivo

PacienteInformado

Activado

Resultados Clnicos y Funcionales

InteraccionesProductivas

Sistema de SaludOrganizacion de atencion

sanitaria

Auto

gestin

Diseo

sistemaprestacin

Apoyo a

ladecision

Sistemas de

informacinclinica

ComunidadRecursos yPoliticas

Equipo desalud

Proactivo

PacienteInformado

Activado

Resultados Clnicos y Funcionales

InteraccionesProductivas

Some Frameworks ..

HowHow can (chronic care) performance be enhancedcan (chronic care) performance be enhanced

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Gestin dela Atencin




Gestin dela Atencin


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HowHow can (chronic care) performance be enhancedcan (chronic care) performance be enhanced

From Improving Chronic Illness CareEd Wagner, MD, Group Health Cooperative of Puget Sound

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UC Berkeley StudyUC Berkeley StudyUse ofUse of Care Management ProcessesCare Management Processes by Type of Chronic Conditionby Type of Chronic Condition

Type of CMPsType of CMPs DiabetesDiabetes

(n = 523)(n = 523)++AsthmaAsthma

(n = 522)(n = 522)

CHFCHF

(n = 526)(n = 526)

DepressionDepression

(n = 497)(n = 497)

Each of 4Each of 4

Chronic IllnessChronic Illness

It TreatsIt Treats

(n = 491)(n = 491)

Patient list or registryPatient list or registry 70.2%70.2% 62.4%62.4% 58.5%58.5% 40.8%40.8% 39.1%39.1%

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

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

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

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

PointPoint--ofof--care reminderscare reminders 51.2%51.2% 36.4%36.4% 33.1%33.1% 22.9%22.9% 19.5%19.5%

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

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

Mean CMP Use (out of 6)Mean CMP Use (out of 6) 3.73.7 2.92.9 2.82.8 1.81.8 --

Mean CMP Use (out of 24)Mean CMP Use (out of 24) -- -- -- -- 11.111.1

Source: D. Rittenhouse et al., Improving Chronic Illness Care: Findings From NationalStudy of Care Management Processes in Large Physician Practices, 2009, Under Review.

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Our system needs changesOur system needs changes

No risk stratificationNo risk stratification

No case nursesNo case nurses

No routine clinical remindersNo routine clinical reminders

No continuum of careNo continuum of care

No activated patientNo activated patient

No regular telemonitoringNo regular telemonitoring

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VA Continues to Exceed HEDIS in 2008VA Continues to Exceed HEDIS in 2008

INDICATORINDICATOR VA 2008VA 2008 VA 2007VA 2007 CommercialCommercial

20072007MedicareMedicare

20072007MedicaidMedicaid

20072007

Breast cancer screeningBreast cancer screening 87%87% 86%86% 69%69% 67%67% 50%50%

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

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

LDL Cholesterol < 100 after AMI, PTCA,LDL Cholesterol < 100 after AMI, PTCA,

CABGCABG66%66% 62%62% 59%59% 56%56% 38%38%

Diabetes: DM control HbA1cDiabetes: DM control HbA1c

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Moving 14 Strategic ProjectsMoving 14 Strategic Projects

Populationstratification

Populationfocus

Prevention andpromotioninterventions

Prevention andpromotion

Expert patient

Patientautonomy

Unified healthrecords

Integratedclinical care

New nurse roles

Socio-healthcontinuum

Financing &commisioning

Continuum ofcare

Multichannelservice center

E-Prescription

Telemonitoringexperiences

Chronic careinfrastructures

Chronic careinnovation center

Personalizedinterventions

Clinical innovation

Visin

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Innovacin desde los

profesionales Generacin de15-25 proyectos de innovacinal ao y extensin de los que

demuestren resultados (~90%)

Centro Servicios Multicanal

Despliegue en Euskadi detodos los servicios para

mediados de 2013

Prevencin y Promocin

Prevencin de aparicin ydesarrollo de

enfermedades crnicas(De_Plan, prevencin

tabquica)

Estratificacin

Estratificacin operativade la poblacin vasca de

forma sistematizada yperidica desde 2011

Autocuidado

Experiencias en lasprincipales enfermedadescrnicas, potenciando la

adherencia y el usoapropiado de los recursos

Historia Clnica

unificada

Implantacinuniversal a finales

de 2011

Atencin clnica

integrada

Un tercio de lasorganizaciones a 2013,

con procesos integrados

Competencias Avanzadas

Enfermera

Formar a 300 enfermerasen los nuevos roles hasta

2013

Receta electrnica

Implantacin efectiva delsistema de receta electrnica

en todo Euskadi en 2012 2013

Experiencias de

telemonitorizacin

Monitorizacin a distancia del 1%de enfermos crnicos severos

(~22.500)

Financiacin y Contratacin

Implantacin plena de unsistema de asignacin

financiera

territorial ajustada

por riesgo

Modelo hospitales subagudos

Implantacin del modelo enhospitales de media estancia ycreacin de nuevo hospital de

crnicos en lava

Centro Investigacin

Cronicidad

Ser un referente internacionalen el conocimiento sobreenfermedades crnicas

Colaboracin sociosanitaria

4 municipios confuncionamiento integrado, 1

hospital con plan de altas conprevencin de dependencia, 1

unidad de ortogeriatra

Strategic Projects: Integrated ApproachStrategic Projects: Integrated Approach

9

2

1

3

4

5

6

1011

8

12

137

14

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Increased use of Technologies : Smart HomeIncreased use of Technologies : Smart Home

Rememberyour

medicine

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WE WILL PROBABLY ALL END UP WITH SOME SORT OFWE WILL PROBABLY ALL END UP WITH SOME SORT OFSTRUCTURED PATIENT EDUCATION : BOTH DIRECT ANDSTRUCTURED PATIENT EDUCATION : BOTH DIRECT AND

REMOTEREMOTE

REMOTE PATIENT

EDUCATION

PATIENT EDUCATION

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With some sort of case manager ( Nurse )With some sort of case manager ( Nurse )

nn Nurses who act a caseNurses who act a case

managers for patients withmanagers for patients with

complex conditions.complex conditions.

nn Their function will be toTheir function will be to

evaluate their physical andevaluate their physical and

social needs and coordinatesocial needs and coordinatetheir care.their care.



Gestin dela Atencin




Gestin dela Atencin


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The payoffThe payoff

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

1Q07

2Q07

3Q07

4Q07

1Q08

2Q08

3Q08

4Q08

1Q09

2Q09

3Q09

4Q09

Registered members

Lab test resultsviewed online

E-mails sent toproviders

Visits to past visitinformation

Online prescriptionrefills

52.6 M

3 M

20.8 M

Source KP

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Change Process:Too Mechanic ??

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Evidence increasing around a few thingsEvidence increasing around a few things

nn Different diseases , similar needs and similar solutionsDifferent diseases , similar needs and similar solutions

nn It is a cultural change: It is deep. It is about the wayIt is a cultural change: It is deep. It is about the waywe work and behaviourwe work and behaviour

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

nn It is therefore less about structural moves than aboutIt is therefore less about structural moves than aboutstaff engagementstaff engagement

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StrategyStrategy

SystemsSystems StructureStructure

Skil lsSkil ls

ValuesValues LeadershipLeadership

STAFFSTAFF

WHERE IS THE CHALLENGE FOR POLICY MAKERS?WHERE IS THE CHALLENGE FOR POLICY MAKERS?

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Top downTop down

Not acceptedNot accepted

Not adaptedNot adapted

No scaleNo scale

No alignmentNo alignment

Bottom upBottom up

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Abandon a Hierarqu ical CultureAbandon a Hierarqu ical Culture

--Apparent stabilityApparent stability

-- Rules y regulationsRules y regulations

-- Simplistic for organizations and problems of todaySimplistic for organizations and problems of today-- PoliticizedPoliticized

Build aBuild a DevelopmentDevelopmentCultureCulture

--Accept complexity and diversityAccept complexity and diversity

-- Promote Local experimentation/researchPromote Local experimentation/research

-- ProvideProvidespacespaceand local autonomyand local autonomy

-- Work with pioneers and early adoptersWork with pioneers and early adopters

-- Better balance top down and bottom upBetter balance top down and bottom up

S Si l f llS Si l f ll

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nn

Evidence growing around a few thingsEvidence growing around a few things

nn Policy makers need to bring this up to first divisionPolicy makers need to bring this up to first division

nn Therefore need to intervene in an aligned way acrossTherefore need to intervene in an aligned way across

macromacro, meso and micro levels, meso and micro levels

nn The power of results. Evidence growing but scalabilityThe power of results. Evidence growing but scalability

still an issuestill an issue

Some Signals for allSome Signals for all

Alignment !

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Meso

Macro

Micro

Alignment !

++++

++++

ben go a

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