Integrated Patient Care

Durhane Wong-Rieger, PhDPresident

Institute for Optimizing Health Outcomes

22/11/2006Integrating Patients in Chronic Disease Management 2

Requirements for Effective Disease Management Integrated, multidisciplinary health services Informed, activated patients HCP support matched to patient capacity and

willingness (to self-manage) WINNERS = HCPs doing ONLY what is HAS to

be done by professional; patient all the rest

What is Patient Self-Management?

The tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include having confidence to deal with medical management, role management, and emotional management.

Report of a Summit. The 1st Annual Crossing the Quality Chasm Summit. 2 0 0 4S e p t e m b e r



Why Patient Self-Management? Nearly half of all Canadians have Chronic

Condition = 16.5 million Canadians As population ages, number of Canadians in

need of chronic care will rise Most patients have multiple risk factors and

multiple conditions requiring management Shift from acute to chronic disease = shift

from provide-based care to patient-based care


Acute versus Chronic DiseaseAcute versus Chronic Disease ACUTE DISEASE CHRONIC DISEASE

BEGINNING Rapid Gradual

CAUSE Usually one Many

DURATION Short Indefinite

DIAGNOSIS Commonly accurate Often uncertain, especially early

DIAGNOSTIC TESTS

Often decisive Often of limited value

TREATMENT Cure common Cure rare

ROLE OF PROFESSIONAL

Select and conduct therapy

Teacher and partner

ROLE OF PATIENT Follow ordersPartner with health professionals, responsible for daily management

HCP and Patient Self-Management


Patient Knowledge (Risks, Benefits, Alternatives, Resources)

Pat

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kills

(P

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Dec

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Patient Directs (Low Risk)“Patient Self-Reliance”

Patient seeks other information; choice on beliefs, values, fears

HCP: challenges, supportsGuidance: Internet,alternatives

Rely on self, faith, othersPatient distrustful of system

HCP Directs (Acute)“Doctor Knows Best”

Patient relies on HCP to make choicePatient does not question; complies

with prescribed treatment Guidance: Healthcare professional

Rely totally on professional judgmentPatient trusts, relies totally

Patient Self-Manages (Chronic)“Patient Informed Choice”

Patient seeks information; makes plans, responsible for choice

HCP listens, informs, supports Guidance: Patient peers, caregivers

Rely on family and peer supportPatient feels empowered

HCP Navigates (High Risk)“HCP Guidance”

HCP defines options, “care maps”; Patient seeks guidance, supportHCP clarifies & recommends

Guidance: Healthcare professionalsRely on professional guidance

Patient feels supported


How HCPs support PSMSelf-management support•the systematic provision of education and supportive interventions by health care staff •to increase patients’ skills and confidence in managing their health problems,

•regular assessment of progress and problems, •goal setting, and problem-solving support.

Patient Self-Management Tools


Patient Role

Tec

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Collaborative Patient Role

Med Tech: Chronic Disease management aids; decision support aids

Med Tech: Patient education materials online

Lo Tech: Patient education materials on paper

Subordinate Patient Role

Hi Tech: Sensor-based surveillance

Med Tech: Video camera surveillance

Lo Tech: Personal supervision and monitoring

Autonomous Patient RoleHi Tech: Advanced Assistive Technologies

Med Tech: Online support groups, provider and health plan comparison engines

Lo Tech: Self-help books on paper

Structured Patient RoleHi Tech: Interactive Telemedicine consultation

Med Tech: Monitoring and messaging system with multiple peripherals

Med Tech: Home and portable testing peripheral

From: California Healthcare Foundation: Patient Self-Management Tools: An Overview, June 2005

How is PSM Provided?

PSM are offered through managed care programs in the USA, such as Kaiser Permanante

In the UK “expert patient” programs mandated for all regional health units

In Alberta, PSM integrated into Calgary Regional Health Authority and provided by all Regional Health Authorities

In BC, PSM available to all residents paid for by BC Health Services

PSM provided in more than 25 countries


Who provides PSM in Ontario? Arthritis Society, Baycrest, Toronto Rehab,

Bridgepoint offer PSM programs for specific clients

Training & support by Institute for Optimizing Health Outcomes and North York Hospital

PSM offered institutions and community-based services in Thunder Bay, Lindsay, Mississauga

Programs coming in Sudbury, Lanark County, Kingston, Ottawa, London, Sault Ste Marie

Programs: Canadian Cancer Society, Kidney Foundation, Northern Diabetes Network, Hep C


Opportunities in Ontario Advent of Local Health Integration Networks and Family

Health Teams = opportunities for PSM to become integrated in Chronic Disease Management

Emphasis in Ontario Health on CDM as part of healthcare reform

Inclusion of PSM as part of Ontario Drug Strategy Ontario Patient Self-Management Network: Collaborative

Initiative among programs and services offering PSM


Vision for Patient Self-Management People with long term disease actively and

effectively manage their care, supported by accessible, relevant and timely training delivered through informed patient centred communities of care.

Institute for Optimizing Health Outcomeswww.optimizinghealth.org

416-969-7431


Integrated Patient Care

Health & Medicine

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