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Practice management in co-morbid patients. Jaime Correia de Sousa, MD, MPH Horizonte Family Health Unit Matosinhos Health Centre - Portugal Health Sciences School (ECS) University of Minho, Braga - Portugal. Objective. At the end of this session the participants will:

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Practice management in co-morbid patients


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practice management in co morbid patients

Practice management in co-morbid patients

Jaime Correia de Sousa, MD, MPH

Horizonte Family Health Unit

Matosinhos Health Centre - Portugal

Health Sciences School (ECS)

University of Minho, Braga - Portugal

objective
Objective

At the end of this session the participants will:

  • Know why we need a new model of care for co-morbid problems
  • Value primary health care orientation in the care for chronic patients
  • Demonstrate the importance of clinical information systems in the management of co-morbidity
  • Recognise the need for a chronic care model
  • Value an approach to teaching and learning about co-morbidity management
introduction
Introduction
  • Most patients with chronic illnesses do not have a single, predominant condition.
  • Most have co-morbidity, the simultaneous presence of multiple chronic conditions.
  • Patients seek care for all of their co-morbidities, not just for a solitary, defining, major condition.

Grumbach, 2003

introduction1
Introduction
  • The majority of visits for care of both an indicator condition and its associated co-morbidities are made to primary care physicians.
  • What is needed is a model of care that addresses the whole person and integrates care for the person’s entire constellation of co-morbidities.

Grumbach, 2003

case study
Case Study
  • Mrs B, head teacher of a primary school, 52 years old, overweight, has diabetes mellitus
  • Doesn’t exercise; easily tired with small efforts; has abad knee that keeps bothering her. The cholesterol level is high.
  • Mrs B blood pressure is regularly checked and is within normal values.
  • Mrs B has smoked all her adult life
case study1
Case Study
  • Mrs B came to see her FP with a bad attack of bronchitis and was told by her doctor that she suspected she had asthma.
  • The doctor prescribed an AB for the bronchitis and an inhaler for the asthma.
  • Mrs B disagreed with her diagnosis of asthma and so took the antibiotics only.
  • Within about 2 weeks she was much better and felt vindicated in her opinion about the asthma.
case study2
Case Study
  • She continued to have difficulty climbing the stairs to the third floor at the top of the school but she put her difficulty down to the ravages of age, overweight and cigarettes.
  • Her peak flow when measured by the doctor in the surgery was 240 litres per minute. It should have been 480 litres per minute.
case study3
Case Study

In 5 m discuss in pairs:

  • Identify the major co-morbid health problems in this patient
  • The impact of a new diagnostic label and models of illness
case study4
Case Study

To discuss later in the group:

  • The most important tasks required to promote a better care for this patient
  • Design a care package for this patient, considering the aims of care and the resources needed
a new model of care
A new model of care?
  • Basic Questions
  • Who should be involved in care?
  • What are our aims?
  • How should we organise care?
basic questions
Basic Questions
  • What is the prevalence of co-morbidity among patients in family medicine?
  • How does this prevalence differ by the sex and age of the patient?
  • How does the prevalence differ between different conditions, particularly acute and chronic conditions?
who should be involved in care

Hospital

doctors and nurses

Patient’s family

Community

Pharmacists

Physiotherapists

Psychologists

Social workers

etc

PHC Team

Family physicians

Nurses

Receptionists

Who should be involved in care?

Patient

what are our aims
What are our aims?
  • Provide the best available care
  • Consider patient’s choices
  • Realistic aims with available logistics (staff, premises, funding)
  • Adequate management of the health systems’ resources
  • Prevention of health inequities
  • Reduce the economic burden of illness in the family
how should we organize care
How should we organize care?

Traditional Chronic Disease Specific Approach

Chronic Care Model

components of the chronic care model
Components of the Chronic Care Model
  • Community
  • Organisation of health care
  • Support self management
  • Design of delivery system
  • Decision support
  • Clinical information systems

Lewis & Dixon, 2004

components of the chronic care model1
Components of the Chronic Care Model

Community

  • Mobilise community resources to meet needs of patients

Organisation of health care

  • Create a culture, organisation, and mechanisms that promote safe, high quality care

Lewis & Dixon, 2004

components of the chronic care model2
Components of the Chronic Care Model

Support self management

  • Empower and prepare patients to manage their health and health care

Design of delivery system

  • Assure the delivery of effective, efficient clinical care and self management support

Lewis & Dixon, 2004

components of the chronic care model3
Components of the Chronic Care Model

Decision support

  • Promote clinical care that is consistent with scientific evidence and patient preferences

Clinical information systems

  • Organise patient and population data to facilitate efficient and effective care

Lewis & Dixon, 2004

primary health care orientation
Primary health care orientation
  • Reconciling the health needs of individual patients and the health needs of the community
  • Community or list based, personally and family oriented
  • Health promotion, prevention, cure, care and palliation and rehabilitation.
  • Covering the full range of health conditions
  • Co-ordination of care with other professionals
  • Pro-active
patient centred model
Patient centred model

1. Exploring both the disease and the illness experience

2. Understanding the whole person

3. Finding common ground regarding management

4. Incorporating prevention and health promotion

5. Enhancing the Doctor-Patient relationship

6. Being realistic

Levenstein (1984)

the importance of clinical information systems
The importance of clinical information systems
  • Appointments systems
  • Enabling call and recall programmes
  • Repeat prescribing
  • Drug alerts (interactions, contraindications, secondary effects)
  • Decision support / expert-system
  • Supporting audit
model of care for patients with co morbid conditions

Chronic care model

Clinical Information System

Patient centred model

Primary health care orientation

Model of care for patients with co-morbid conditions
model of care for patients with co morbid conditions1

Clinical Information System

Chronic care model

Patient centred model

Primary health care orientation

Model of care for patients with co-morbid conditions
slide26

Traditional Model

Chronic Care 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

Counsel re: Lifestyle Changes

Deal with

Acute Attack

of Disease

Review Labs

Reinforce Positive Health Behaviours

Access Social/Other Services

Talk with Family

Reassure

Complete Forms

Diagnose

Review Care Plan

General Referral

Consultation 10 minutes

Review/Adjust Rx and Tx

Review History

Routine Preventive Care

Modify and/or Negotiate Care Plans

Source: KPCMI

THE TRANSFORMATION

so how do we make this paradigm shift
So, how do we make this paradigm shift?
  • Start with better data extraction and information analysis to inform decisions
  • Implement case management for patients with highest burdens of disease
  • Implement guidelines for managing diseases and consider care co-ordination
  • Support self management and self care
  • Measure progress and achievement; and adjust process when necessary
conclusions
Conclusions
  • Chronic illnesses are becoming the main activity of family physicians
  • Chronic diseases don’t exist isolated
  • Frequently, patients have more than one condition
  • A generalist approach is necessary
  • Shared care is important… but
  • We need a family practice based Chronic Care Model