1 / 19

Today ’ s Agenda

Chronic Disease Management: Providing fully integrated support. The burden of chronic disease Supported care management Patient health coaching Key considerations. Today ’ s Agenda. 1. 1. The burden of chronic disease Supported care management Patient health coaching Key considerations.

mathilde
Télécharger la présentation

Today ’ s Agenda

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Chronic Disease Management:Providing fully integrated support The burden of chronic disease Supported care management Patient health coaching Key considerations Today’s Agenda 1 1

  2. The burden of chronic disease Supported care management Patient health coaching Key considerations Today’s Agenda 2 2

  3. The situation:a global healthcare crisis World Health Organization (WHO) • The global burden of chronic diseases continues to grow • Tackling it constitutes one of the major challenges for development in the twenty-first century1 • Major chronic diseases currently account for: • ~60% of all deaths • ~47% of the global burden of disease • Figures are expected to rise to 73% and 60%, respectively, by 20202 1 The World Health Report 2002. Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 2 World Health Organization, Report by the Secretariat. Prevention and control of non-communicable diseases: implementation of the global strategy. World Health Organization, 16 January 2008.

  4. The solution: prevention & control World Health Organization (WHO) • Prevention - Reduce common risk factors: • tobacco consumption • unhealthy diet • physical inactivity • harmful use of alcohol • Control – Enhancing health care by incorporating standards of care into cost-effective interventions World Health Organization, Report by the Secretariat. Prevention and control of non-communicable diseases (NCD): implementation of the global strategy. World Health Organization, 16 January 2008. 4 4 4

  5. The burden of chronic disease Supported care management Patient health coaching Key considerations Today’s Agenda 5 5

  6. The patient support program • A population-wide approach with a ‘Whole person’ focus • Effective communication with the primary health care team • Intensity of support varied according to need • Segmentation and definition of work approaches • Telephonic nursing and health coaching • Case Management for high risk patients • Self Management Support • Personalised care planning that fully involves the patient • Patient education that includes support for behaviour change • Full use of various media (telephone, SMS, internet, mail etc) • Process and outcomes measurement along with evaluation 6

  7. STATUS 1: HIGH RISK CARE MANAGEMENT Goal: Avoidance of hospitalisation Care Management:Primary Nursing, Telephonic/Internet Wellness: Monitoring for Complications,Medicines Management, Community Forums 1 2 STATUS 2: CHRONIC CARE MANAGEMENT 20% of Population Goal: Reduce Complications Care Management:Team Nursing, Telephonic/Internet Wellness:Empowered participants, Community Forums, Standards of Care 3 4 STATUS 3: SUPPORTED SELF CARE Goal: Prevent Complications Care Management:Education/Coaching, internet Wellness:Online Resources, Text Messaging, Community Messaging Goal: Prevent Complications Care Management: Education/Coaching, internet Wellness: Online Resources, Text Messaging, Community Messaging 80% of Population STATUS 4: HEALTH & WELLNESS Goal: Keeping the wider population healthy Wellness:Online Resources, Text Messaging, Community Messaging, Lifestyle Management

  8. eConnect Clinical Information Health Management System Health Management System Health Care Team Portal participant Information for the GP Internet Personal Health Portal An integrated system of care p Two way text messaging E-mail reminders Home monitoring Health assessments, care plans and education tools online

  9. Self Care Web Portal

  10. Success Factors for a Program • Strong clinical leadership & communication • Highly skilled & empathetic clinical team • Access to patient information data • Content based on the best available clinical evidence • Fully supportive infrastructure • Data managementand informatics • Full use of available technologies • Call centre optimisation • Effective communication & liaison • Compliance with local statutory legislation • Ongoing training & education • Demonstration of positive health and economic results within a 1 to 3 year cycle 10

  11. The burden of chronic disease Supported care management Patient health coaching Key considerations Today’s Agenda 11 11

  12. Evolution of patient coaching (US) Second Generation Third Generation First Generation 1980s - 1995 Facility based programs Fully reliant on GPs and specialists Face-to-face interaction Reactive, disease specific Few objectively quantified results Largely pilot programs • 1995 -2001 • Physician oriented • Mailed educational information • Some telephonic outreach • Introduction of nurses • Still reactive, though more patient oriented 2002 - today Patient-centred High risk, DM and self management approach Proactive and total population based Highly scalable telephonic model Expert systems & remote monitoring Validated outcomes Grounded in evidence based medicine First Generation Second Generation Third Generation 12 12

  13. Effectiveness of Patient Coaching Programs CAD • Less evidence available • Longer time to benefit • Reduced myocardial infarctions4 • Decreased LDL5 • Reduced hospitalizations6 • Reduced readmissions7 Adult Asthma • Decreased hospitalizations1 • Decreased ER visits1 • Decreased non-productive workdays1 • Reduced uncontrolled episodes2 • Improved quality of life3 1 Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc (Wash DC ). 2006;46:133-47. 2 Levy ML, Robb M, Allen J, Doherty C, Bland JM, Winter RJ. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respir Med. 2000;94:900-908.. 3 Cowie RL, Underwood MF, Little CB, Mitchell I, Spier S, Ford GT. Asthma in adolescents: a randomized, controlled trial of an asthma program for adolescents and young adults with severe asthma. Can Respir J. 2002;9:253-59. 4 Chan WM et al. The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong. .). J Telemed Telecare 7(1): 38-46 . 2001. Ref Type: Generic 5 Walsh MN, Simpson RJ, Jr., Wan GJ, Weiss TW, Alexander CM, Markson LE et al. Do disease management programs for patients with coronary heart disease make a difference? Experiences of nine practices. Am J Manag Care. 2002;8:937-46 6 Wheeler JR, Janz NK, Dodge JA. Can a disease self-management program reduce health care costs? The case of older women with heart disease. Med Care. 2003;41:706-15. 7Young W, Rewa G, Goodman SG, Jaglal SB, Cash L, Lefkowitz C et al. Evaluation of a community-based inner-city disease management program for postmyocardial infarction patients: a randomized controlled trial. CMAJ. 2003;169:905-10. 13

  14. Effectiveness of Patient Coaching Programs Diabetes • Improved glycemic control1 • Improved provider monitoring (eye exams, foot exams, etc.)1 • Decreased microvascular complications2 • Decreased inpatient healthcare utilization3 CHF • 30% reduction in hospital re-admissions4 • Decreased hospitalizations5 • Improved quality of life6 • Decreased mortality7 • Improved prescribing practices7 1Goetzel R, Ozminkowski R, Villagra V, Duffy J. Return on Investment in Disease Management: A Review. Health Care Financing Review. 2005;26:1-19. 2 Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-93. 3 Sidorov et al. 4 Gonseth J, Guallar-Castillon P, Banegas JR, Rodriguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J.2004;25:1570 5 Whellan DJ, Hasselblad V, Peterson E, O'Connor CM, Schulman KA. Metaanalysis and review of heart failure disease management randomized controlled clinical trials. Am Heart J. 2005;149:722-29. 6Randomised trial of telephone intervention in chronic heart failure: DIAL trial. BMJ. 2005;331:425. 7 Galbreath AD, Krasuski RA, Smith B, Stajduhar KC, Kwan MD, Ellis R et al. Long-term healthcare and cost outcomes of disease management in a large, randomized, community-based population with heart failure. Circulation. 2004;110:3518-26. 14

  15. Effectiveness of Patient Coaching Programs COPD • Reduced hospital admissions1 • Reduced ER visits1 • Reduced unscheduled physician visits1 • Decreased need for rescue meds2 • Decrease in missed work time2 General Conclusions • Diabetes and HF- the most published studies and most robust outcomes (utilization and quality) • CAD and COPD- fewer studies although examples do exist that show decreased utilisation and improved outcomes 1 Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med. 2003;163:585-91.. 2 Gadoury MA, Schwartzman K, Rouleau M, Maltais F, Julien M, Beaupre A et al. Self-management reduces both short- and long-term hospitalisation in COPD. Eur Respir J. 2005;26:853-57. 15

  16. Utilisation and Clinical Improvement Independent, third party analysis by BlueCross BlueShield and their consulting actuaries Cap Gemini Ernst & Young Full care enhancement programme covering Levels 1-3 Validated >2.5 : 1 Return On Investment (ROI) in the first year 2% to 3% reduction in overall medical trend for the entire health plan How Broadening DM’s Focus Helped Shrink One Plan’s Costs by William R Gold, M.D., CMO BCBS Minnesota and Peter Kongstvedt, M.D., Vice President CapGemini Earnst & Young. Published in Managed Care, November 2003. 16

  17. The burden of chronic disease Supported care management Patient health coaching Key considerations Today’s Agenda 17 17

  18. Key considerations • Total population approach to health • Attention to lifestyle & health promotion • Health coaching & behaviour change management • Wide range of support approaches/media/IT • Effective communication for all health providers • Evidence based clinical standards and pathways • Patients as fully involved participants 18

  19. Creating a healthier world, one person at a time... enquiries@healthways.com 19

More Related