CHRIS DOWSE PROGRAMME LEAD CHRONIC DISEASE MANAGEMENT.
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Transcript of CHRIS DOWSE PROGRAMME LEAD CHRONIC DISEASE MANAGEMENT.
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CHRIS DOWSEPROGRAMME LEAD
CHRONIC DISEASE MANAGEMENT
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– Learning and evidence so far
– What is a systematic approach to CDM?
– Getting started
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CASTLEFIELDS HEALTH CENTRE (UK)
• 15% reduc’n unplanned admissions• 31% reduc’n hospital LOS (6.2 to 4.3)• Total hospital bed days fell by 41%• Significant savings• Better patient experience• Improved integration + more appropriate referrals
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VETERANS ADMINISTRATION (USA)
• 35% reduc’n urgent care visit rate• 50% reduc’n hospital bed days
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EVERCARE (USA)
• 50% reduc’n unplanned admissions without detriment to health
• Significant reductions in medications
• 97% family and carer satisfaction
• High physician satisfaction
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NHS-ADAPTED EVERCARE
• 3% of target pop’n = 30% unplanned admissions for that age group• many admissions avoidable (urinary tract infection, dehydration)• 55-87% high risk pop’n not accesssing DNs & Social Services• polypharmacy
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NW LONDON SHA Case mgt releases significant
capacity
• 29% total medical specialities bed days used by 65+ with 2+ unplanned admissions.
• Reduc’n occupied bed days 7.5 -16.6% • = up to £1.15m for PCTs
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NW LONDON SHA (cont)
• Reduc’n A&E adult attendances 2-3%• Reduc’n GP activity for 75+ up to 53% home visits; 82% OOHs; 19%
general appts.• To set up case mgt - £173k per PCT
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THE TRANSFORMATION
Deal withAcute Attackof Disease
Counsel re: Lifestyle ChangesReview
LabsAccess
Social/Other Services
Reassure
Diagnose
General Referral
Reviwe/Adjust Rx and Tx Routine
Preventive Care
Modify and/or Negotiate Care
Plans
Review History
Review Care Plan
Complete Forms
Talk with Family
Reinforce Positive Health
Behaviours
Traditional Model
SICKNESS CARE MODEL (Current Approach - Physician Centric) • Care is Proactive
• Care delivered by a health care team
• Care integrated across time, place and conditions
• Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology
• Self-management support a responsibility and integral part of the delivery system
Chronic Care Model
Consultation 10 minutes
Source: KPCMI [21]
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Population Management: More than Care & Case Management
Intensive
or Case Management
Assisted Care or Care Management
Usual Care with Support
Level 170-80% of a
CCM pop
Level 2High risk members
Level 3Highly complex members
Targeting Population(s)
Redesigning Processes
Measurement of Outcomes & Feedback
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COMPONENTS OF EFFECTIVE CDM (1)
• Pop’n management & risk stratification• Effective registers and integrated records• Evidence based “care pathways”• Disease management and care co-ordination
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COMPONENTS OF EFFECTIVE CDM (2)
• Self care/self management - with information and support
• Active management of at risk patients• Primary/secondary/social care co-ordination
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KEY PRINCIPLES OF CASE MGT.
• Enhancing PC team role thro’ multi-disciplinary approach
Stratifying patients for highest risk
• Providing proactive care to patients with highest burdens of disease
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KEY PRINCIPLES OF CASE MGT.
Professional, usually clinical, case managers co-ordinating Care Plan
Working across boundaries and in p/ship with secondary care clinicians and social services
Care Team managing patient journey proactively and seamlessly thro’ all parts of health & social care system.
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BE SYSTEMATIC - GETTING STARTED
• Identify CD pop’n within PC• Move to pop’n mgt - stratify for risk• Improve disease mgt: Care Plans; review/ recall/ reassessment; care
co-ordination• Support self management throughout• Identify pop’n with highest burdens of disease [ 2+ unplanned
admissions; 4+ meds; etc] • Apply case mgt principles - proactive care