Frede Olesen, professor, MD, PhD, FRCGP (hon.) The Research Unit for General Practice

1. Frede Olesen, professor, MD, PhD, FRCGP (hon.) The Research Unit for General Practice University of Aarhus, Denmark Fo@alm.au.dk

2. UNIVERSITY OF AARHUS DENMARK Frede Olesen, Res. Unit for GP, Univ. of Aarhus, Denmark

3. Use of the health care system1000 persons followed for 1 month 750 have symptoms 500 take a drug 250 attend the GP 10 go to hospital 1 on univ-hosp. Kamper Jørgensen, SIF, N Engl J. Med.2001 2021-24

4. Hospital doctors and GPs activity present big variations= possible to change somethingEks: percentage of practice pop. who are frequent attenders in 261 practices Frequent attender = belongs to upper 10% of attenders in a county. N=255 GPs. Vedsted et al. 1998

5. Refferals from GP Treated in GP % Referred % Relative % 90 91 10 9 10

6. To the doctor Self care % Att. health care% Relative % 90 91 10 9 10

7. State of the art…. All international research shows… • Primary care and General Practice essential to obtain population based cost effective high quality health service • Gate keeper/gate advisory systems outperform open access to secondary care …this is old knowledge but not allways realized among politicians and health care planners Starfield B, WHO and others

8. Challenges in 2100 century… • More elderly people • More patients with chronic diseases • (a disease > 6 month, deminish function or life expectancy) • > 25 % of a population has a chr. disease • 50% more than one chr. disease • > 50 % of all attenders in GP • > 80 % of all health care costs • 5% of population takes 50% of cost to health care

9. What to do… ?

11. Feachem Concluded: Feachem concluded that for similar expense KP outperforms NHS • KP delivers better access and similar or better quality • KP does this through: • more efficient use of hospital • integration • use of information systems

12. Hospital Utilization - Days/1000

13. Over Half of KP’s Total Costs Are Incurred by 5 Percent of Members

14. The new chronic disease paradigm… Sick-care Population Based Chronic Condition Care Public Health

15. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

16. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

17. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

18. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

19. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

20. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

21. The solution … From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound JAMA. 2002;288:1775-1778 JAMA. 2002;288:1909-1914

22. Leadership essential A vision Create integration Invest in IT Implement

23. Make good and aligned incitives fo@alm.au.dk

24. Joint guidelines between hospital and general practice Clinical Research Evidence Implementation Benefit 20% 80%

25. Register the target group

26. Intensive Management Leverage available resources to optimize health status and coordination of care Care Management Enhance self-care skills; provide clinical management using care paths and protocols Self-care Support Routine care with decision support technology and programs to assist members in developing/ improving self-care skills Risc-stratification of the target group "Sick-care" 1 2 3

27. Informatics – populations based Gen. Practice WEB-record - info to pt - joint part of rec. - info to prof. Patient/ Citizen Hospital Munici- pality.

28. 4. Information Systems Physician Personal Home Page A Personal Portal to the regions health care and the selected GP 28

29. Tools for non-clinicians

30. Patient empowerment MyDiabetes Action Plan This week I will________________ (What) ______________________________(How Much) ______________________________(When) ______________________________(How Many) How confident are you?___ 0=not at all 10=totally confident Reward Be sure your goal includes: 1. What you’re going to do 2. How much you’re going to do it. 3. When you’re going to do it. 4. How many days a week you’re going to do it. Day Check off Comments Tuesday________________________________________ Wednesday______________________________________ Thursday________________________________________ Monday________________________________________ Friday__________________________________________ Saturday________________________________________ Sunday_________________________________________

31. A future model The hospitals The community The municipality The region General practice

32. Level 1 therapy Support to 2 and 3 Patientsupport, Teaching and education The hospitals The community The municipality The region General practice Take responsibility in good planning Routine control Level 3 and most 2

33. How to do it in reality?Italy has shown the way forward for centuries! To elect the pope: they must find a joint solution

34. Theory • you know everything • - nothing works as expected • Organisation • nothing works as expected • - everybody knows why • General practice • everything works • - nobody knows why

35. Thank you for your attention FO@alm.au,dk