Complex Chronic Disease Patients better results at a better cost

Complex Chronic Disease Patientsbetter results at a better cost

Gerry Bédard, MDAlain Larouche, MDGuylaine Chabot, M.P.A.June 2012

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PRESENTATION PLAN

1. The number one issue: complex chronic diseases2. The Concerto health model3. The showcase4. An outstanding living laboratory5. The implementation process

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THE NUMBER ONE ISSUE

Complex chronic disease (CCD) Complex chronic disease: several CDs affecting one patient The accumulation of CDs: 25% of the population has two or

more CDs A pathological problem in itself: the diseases have a

harmful synergistic effect on each other Uncoordinated care: a harmful effect on complex CDs Prevention: acting on health behaviours

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% of people hospitalized according to condition

People with 3 or more chronic diseases account for 71% of all admissions.

NOTE

Number of chronic diseases

0 1 2 3 4 5+0%

10%

20%

30%

40%

50%

60%

52%

24%

11%

7%4% 3%4%

7%

12%

17%

23%

31%

% of population with or without chronic diseases total % of hospitalizations

Impact of chronic diseases on the health system

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Ratio population/expenditures according to condition

People with 5 chronic diseases or more (3% of the population) account for the same expenditures as people with no chronic diseases (52% of the population).

NOTE

Ratio

pop

ulati

on/e

xpen

ditu

res

Source: Medical Expenditure Panel Survey2001

Number of chronic diseases

0 1 2 3 4 5+0

2

4

6

8

10

12

14

16

18

1.00

2.68

5.01

6.99

9.18

16.31


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3% of the population • 50% of inpatient days

Data validated for the entire Québec population

5,000 FTE nurses required for this care


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THE CONCERTO HEALTH MODEL

Description Optimal, front-line care management of a population

registered with a family medicine group (FMG) Complete interdisciplinary team: physicians, clinical nurses,

other professionals Services adapted to patient categorization Care and service pathways Proven information system

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Approach

Population health• Services offered close to the patient’s home• Holistic approach• Health prevention and promotion• Screening for chronic diseases

Priority given to chronic diseases• Categorization• Multimorbidity: complex chronic patient• Collaborative approach: interdisciplinary team with the

patient

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4Complex

cases3

Patients with highrisk of complications

2Chronic diseases

1Healthy population

Chronic disease management pyramid• From the “Chronic

Care Model” by Ed Wagner et al.

• Improved (Canadian version)

The cornerstone of the model

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19 target diagnoses and conditions

Diabetes High blood pressure (HBP) Dyslipidemia COPD Asthma Chronic heart failure (CHF) Arteriosclerosis disease Chronic renal failure (CRF)

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19 target diagnoses and conditions Mental health• Depression• Anxiety disorders• Attention deficit hyperactivity disorder (ADHD)

Oncology and palliative care• Chronic pain

Dementia and loss of autonomy Neonatal follow-up Pregnancy follow-up Regular medical exam• Screening• Prevention and promotion

Roles of health professionals

FMG• Offer access to continuous, quality services

Interdisciplinary team• Personalize the services offered• Optimize the family physician/clinical nurse duo

(ongoing collaboration)• Foster the expertise potential of each professional

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Clinical nurse (university degree)• Provide personalized patient follow-up• Offer relevant instruction• Promote self-care• Coordinate care (key role)• Ensure smooth case management for complex patients

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Physician• Diagnose clinical conditions• Prescribe the care trajectories

– Make sure of patient’s follow-up• Support the nurses and other professionals• Provide the periodic medical follow-up required

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Other professionals• Support the nurses according to the care trajectory• Participate actively in the care of patients at high risk of

complications and with complex cases• Coordinate care and services with the other CSSS

professionals– Front-line care– Specialized care

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Health and social services centre (CSSS)• Relocate health care professionals to FMGs• Validate collective prescriptions (director of nursing)• Coordinate activities in the region• Provide and coordinate access to services

– Home care– Specialized clinics– Medical specialists– Technical support

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Roles of health professionals Concerto health group• Develop care and service pathways• Produce collective prescriptions• Categorize patients• Identify frequent users• Coordinate professional training• Support health care professionals in managing change

– Organization of work– Professional practices– Adoption of computerized solutions

• Evaluate and improve administrative processes on an ongoing basis

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Tools Care and service pathways based on consensus and

relevant data• Screening• Clinical assessment• Teaching• Lab tests• Decision support• Treatments• Interprofessional references• Follow-up according to clinical condition

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Tools

Technology platform• Interprofessional intervention tool• Exchange of information with patients

– Patient portal– Telehomecare (telemonitoring and remote follow-up)

• Database– Manage population data– Manage clinical processes– Manage results

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Tools

Decision support Collective prescriptions: sharing of reserved medical

activities• Lab tests• Therapy adjustments

Report to physician

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Training program for all professionals

Motivational approach• Éducoeur-en-route• Health coach

Collaborative approach: the real interdisciplinary work including the patient

Case management Specifics and complications per pathology Post-training support

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Dynamic assessment

Dashboard• Clinical process tracking indicators

– Accessibility– Continuity– Appropriateness– Productivity– Care quality– Satisfaction– Societal costs

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Dynamic assessment

Dashboard• Outcome indicators

– Behavioural changes– Empowerment– Improved state of health– Level of use of services

Emergency room stretchers Hospital beds Beds in long-term care centres (CHSLD)

IIIP + case management

IIIP*

Care

traje

ctorie

sPr

even

tive

scre

enin

g

4Complexcase

s3Patients with high

risk of complications

2Chronic diseases

1Healthy population

Population

Categorization

Strategic clinical alliance

CSSS

Family physiciansFront line

Relocation of interdisciplinary team

• Care pathways• Protocols • Collective

prescriptions• Teaching

*IIIP: Individualized interdisciplinary intervention plan

Personalization of care

(multipathologies + comorbidities)

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Chronic disease management

system

Population health management

Coordination of care and services –

THE CHALLENGE

Telehomecare - telemonitoring

Health portal

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Interdisciplinary training

Optimal medication management

TeachingLifestyle habits

(Éducœur-en-route)

Measuring societal costsProactiveness

Productiveinteraction

Measuring satisfaction and quality of life

Well-trained, proactive staff Well-informed patients

and loved ones who are partners in care giving

THE SHOWCASE

Degree of progress 17 months of activities 2 FMGs in Sud de Lanaudière Collaboration agreements• Ministry of Health and Social Services• Regional Health Board of Lanaudière• Sud de Lanaudière Health Center (CSSSSL)• Concerto Health Group

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Interdisciplinary team

Family physicians (20) Nurses (10 FTE) Pharmacist (0.8 FTE) Nutritionist (0.8 FTE) Respiratory therapist (1.0 FTE) Social workers (2 FTE) Psychologist (0.8 FTE) Physiotherapist (0.4 FTE) Occupational therapist (0.4 FTE)

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HPB/Dysl

ipemia

Dyslipem

ia only

HBP only

Diabete

s/HBP/D

yslipem

ia

Diabete

s/Dysl

ipemia

Diabete

s/HBP

Diabete

s only

2+ CDs

0

200

400

600

800

1000

1200

0%

10%

20%

30%

40%

50%

60%

70%

80%

14367

216

547

172 177 199

1039

9% 4% 14%

36%

11% 12% 13%

68%

Patient distribution according to diagnoses or groups of diagnoses among 2065 patients registered* on May 11, 2012

Number %

Patients with 3 diagnoses make up the largest group

Among patients with at least one of the

diagnoses, 68% have 2 or more diagnoses

* including 544 patients investigated or monitored mainly for respiratory problems (not shown on the chart)

Degree of progress

243 frequent users identified• 3 hospitalizations or more in 3 years• 5 events or more in 3 years

Interdisciplinary intervention plans• 65 completed in June 2012

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Results: trends

Satisfaction among nurses with regard to training• High rate: > 80%

Continuity of care• 3 visits or more plus

monitoring by the same nurse: 95.7% of patients

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Data gathered from October 2010 to February 2012 and produced on April 10, 2012.

Table showing the change in patients’ state of health based on HbA1c analysis results (1st period 0 – 6 months)

·21.95% of patients improved their result.·28.3% of patients maintained their result at the target level.·37.9% of patients remained stable, but not at the target level.·11.8% of patients saw their state of health deteriorate.

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2012 2013 2014

0 $

20,000 $

40,000 $

60,000 $

80,000 $

100,000 $

120,000 $

140,000 $

160,000 $

Changes from 2012-2014 in the cost of care professionalsversus CSSSSL and network efficiency gains

Clinical Team Costs $ Efficiency Gains $ (hospital only) Efficiency Gains $ (network)

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Results: trends

CSSSSL efficiency gains: costs recovered after a little more than 3 years of operation

Overall efficiency gains (CSSSSL and network): costs recovered after 2 years of operation

In the longer term: reduction in the expenditure growth curve

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Legal framework

Patient consent Confidentiality rules governing personal information Rules governing information access, retention and

circulation Rules for processing redacted information

Integrated Clinical Solutions

CHRONICDISEASE

MANAGEMENT

REMOTEPATIENT

MONITORING

PERSONALHEALTH

RECORDS

CHRONICDISEASE

MANAGEMENTSOLUTION

Technology Partner

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Pharmaceutical partners

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SanofiAstra-ZenecaBristol-Myers-SquibbPfizerShire

• Interdisciplinary training program

• Societal costs• Optimal medication

management

Collaborators Institut de recherches cliniques de Montréal• Éducoeur-en-route

Claude Sicotte, PhD: full professor, Faculty of Medicine, Université de Montréal• Dashboard

Fernand Couillard, MD, psychiatrist• Mental health care pathways

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OUTSTANDING LABORATORY: Living Lab

Better informed and monitored patients: “chronically

well” Innovative, advanced clinical practices for nurses Physicians better supported in their practice Demonstrated efficiency of the front line in response

to the health needs of the population Added value for the network’s performance Cutting-edge contribution for the evolution of health

care systems

Documents

Complex Chronic Disease Patients better results at a better cost