ICDM/ICSM ANOVA-MOPANI

2014

Dr Shaidah Asmall

IDEAL CLINIC DESCRIPTION

Ideal ( concept) refers to perfect/ ultimate/ model Ideal clinic – in this context the concept refers to a facility (clinic) which has been developed to a perfect/ ultimate model to be used as an example for other facilities to benchmark.

DESCRIPTION

• A clinic that ensures the provision of quality health services to the community through: – Good infrastructure – Adequate staff – Adequate medicine and supplies – Adequate bulk supplies – Good administrative processes – Optimal clinical care -use of applicable policies, protocols,

guidelines pertaining to diagnoses and treatment – Leveraging partner and stakeholder support – Cooperation with other government departments as well as

with the private sector and non-governmental organizations to address the social determinants of health

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District Health System that Supports the Ideal PHC Facility

• Capable District Management Team

• PTICRM

• Improved Procurement System

• Functional referral System

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COMPONENTS AND ELEMENTS

Administration Clinical

Guidelines & ICDM

Medicines, supplies & lab

services

Staffing & professional

standards

Availability of a doctor

Communication Health

Information Management

Infrastructure & Support services

District Health Support Systems

Partners & stakeholders

ICSM Integrated Clinical Services

Management

ICSM Integrated Clinical Services Management

Acute and Minor Ailments

MCWH-Preventive /Promotive

Chronic Disease Management

Unplanned

Planned appointments

Planned Appointments

Integrated Chronic Disease Management Model

What is the ICDM?

Integrated Chronic Disease Management (ICDM) is a model of managed care that provides for integrated prevention, treatment and care of chronic patients at primary healthcare level (PHC) to ensure a seamless transition to ‘assisted’ self-management within the community by taking a patient-centric view that encompasses the full value chain of continuum of care and support.

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Purpose of the ICDM • To achieve optimal clinical outcomes for patients

with chronic diseases (communicable and non-communicable) by: – Ensuring the coordination of care and

transitioning to self-management at a community level

– Using the health system building block framework, to improve the efficiency and decrease the strain on the health care system

– Maintaining the economic and social productivity of the patient

– By developing an individual's sense of responsibility for their own health

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Conditions included as Chronic Diseases

–Non-communicable Diseases

Diabetes,Hypertension,IHD,COPD,Asthma

–Persistent Communicable Diseases

HIV(Pre-ART & on ART),TB

– Long term Mental Illness

Depression,Anxiety

–Persistent Physical Impairments

Strokes,Cerebral Palsy

Pillars of the ICDM

• Primary prevention- identification of high risk individuals at community and facility level and appropriate interventions

• Secondary prevention through planned, optimal evidence based clinical care using an interdisciplinary approach

• Cultivate a sense of individual responsibility through assisted self-management at community level

• These 3 pillars are supported through a sustained, strengthened and integrated health system.

Baseline Assessment

• Vertical services

• Specific days for consulting chronic NCD patients or EPI /ANC i.e. service was not offered daily yet called supermarket approach

• Inefficient process flow at all facilities – – All patients wait in one area for vital signs monitoring-

resulting in bottlenecks and extending patient waiting times

– No signage directing patients to appropriate area for waiting

– No patient scheduling mechanism in place - given only return dates for follow up-thus inappropriate staff allocation.

• No mechanism for tracking defaulters

• Poor quality of clinical records

• Very little health promotion

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Integrated Clinical Services Management

Facility Community

Optimal Clinical Outcomes

Operational Efficiency & QoC

Individual Responsibility

Re-organisation Clinical management Assisted self management

Health system

HR HMIS Pharmaceuticals Equipment Financing Partners

Stewardship and ownership

HEALTH SERVICE RE-ORGANISATION

•Re-organisation of patient flow

•Designated waiting areas

•Designated consultation area

•Designated vital signs station

•Appointment scheduling •Single administrative point •Pre-appointment retrieval of clinical records •Integration of clinical care •Pre-dispensing of medication

CLINICAL MANAGEMENT SUPPORT

• Chronic patient record

• PC 101 training and application of algorithmic based clinical guidelines

• Health promotion compendium- still to be developed

• Supervision and support by district clinical specialist teams

ASSISTED SELF MANAGEMENT

• Health promotion and education at communicty level

• Identification of at-risk patients within the household by point of care screening

• Point of care testing and screening

• Support groups and adherence clubs

• Medication delivery (courier service)

IDCM model components

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Health Education & Awareness Screening Referrals

Mentoring & supervision and strengthening of referral

Primary prevention & Screening Household visits- adherence monitoring and identification of complications Referrals

PHC clinic level- treatment and prevention of complications

Oversight and addressing systemic challenges

Organised system

Percentage decrease in median total time for chronic patients between

December 2011 and Jan 2013

28%

10% 12%

36%

45%

77%

20%

49%

44%

31%

25%

64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% change from baseline

Change in quality of clinical records- baseline/3 and 6 months post training

76%

69% 65%

50%

22%

33%

90%

95%

81% 76%

33%

40%

92% 88%

83%

68%

35%

44%

0%

20%

40%

60%

80%

100%

120%

DKK DKK contr WRH WRH cont BBR BBR cont

Baseline 3 months 6 months

Cumulative Remaining in Care

Process for Scale up • Evolution of ICDM to ICSM (Integration of Clinical Service

Management ) • The implementation of the ICDM is feasible with limited resources. In

order to scale up the ICDM across all 52 districts it is recommended: • Provincial Senior management be briefed at a strategic level • Provincial programme managers are informed and the ICDM is

included in their key performance areas • The provincial team should select the districts to commence the

implementation • The district should select a sub-district/s to start the

implementation and based on the specific contextual lessons learnt scale up across the district

• A campaign using community media should be launched simultaneously to sensitize patients about the ICDM and changes in management of chronic conditions as well as other services .

Possible Role of Partner Organisations – Assist in rollout of ICDM-identify ~10 best performing

facilities

– Pharmaceutical System Strengthening

– Training of clinical & non clinical staff on appropriate policies, procedures and guidelines -NCS

– Mentorship of the clinical staff to enhance services

– WBOT-CHW training

– Supporting districts and facilities with human resources - not restricted to ART services only but on improving health service • Doctors

• Pharmacist

• Post Basic Pharmacy Assistants

• Data Capturers

• Quality Monitors and Mentors