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Continuous Care in Chronic Conditions Learning's from a project between Bispebjerg Hospital and Copenhagen Community. “Improving Care in Europe and the US: Towards patient-centered, proactive and coordinated systems of care” Anne Frølich, MD, Ass. Professor,

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slide1

Continuous Care in Chronic ConditionsLearning's from a project between Bispebjerg Hospital and Copenhagen Community

“Improving Care in Europe and the US: Towards patient-centered, proactive and coordinated systems of care”

Anne Frølich, MD, Ass. Professor,

Department of Health Services Research, Bispebjerg Hospital, University of Copenhagen

project members
Project members
  • Jens Egsgaard
  • Carsten Hendriksen
  • Dorte Høst
  • Helle Schnor
  • Cecilia Ravn Jensen
goals for the project
Goals for the project
  • Improve care in chronic conditions focusing on continuity
  • Develop a model that support chronic care
slide4
Focus on Chronic conditions Recommendations for Improvement of Care in Chronic Conditions, National Board of Health, Year 2005

Prevalence rates of the most common chronic conditions

COPD 200.000 4%

Type 2 DM 200.000 4%

CHF 200.000 4%

Muscle- 200.000 4%

Skeletal conditions

Osteoporosis 300.000 6%

national board of health publication with recommendations patient healthcare and society
National Board of Health – Publication with Recommendations Patient, Healthcare and Society
reaching for a more coordinated healthcare system
Reaching for a more Coordinated Healthcare System

The Structure Reform:

  • Reduced the 14 counties to 5 regions
  • 278 Municipalities was reduced to 98

The new health act:

  • Mandatory Healthcare Agreements to avoid fragmentation:
  • Focus on discharge from hospital for weak elderly patients, agreements on social services for people with mental disorders and agreements on prevention and rehabilitation
new healthcare act
New Healthcare Act

One of the major changes following the new health care act is transfer of the responsibility for rehabilitation and health promotion services from the regions to the municipalities

coordination of care
Coordination of Care

Macro level State level, healthcare agreements between regions and municipalities

Meso level Organizational level

Micro level Patient-provider level

methods and material
Methods and Material

Copenhagen Municipality: 503.000 citizens

Østerbro local area: 80.000 citizens

Bispebjerg Hospital: 700 beds and 3.500 employees

General practitioners: 57 GP’s, 50% in solo practices

Conditions: COPD

Type 2 diabetes

Heart failure

Balance problems

rehabilitation in the hospital and at the municipality level health center
Rehabilitation in the hospital and at the municipality level – health center

Activities in a rehabilitation unit:

  • Primary assessment, physical tests and quality of life tests
  • Physical Training
  • Smoking Cessation
  • Patient Education
  • Dietician Counselling
  • Psychosocial support
  • Planned follow-up
coordination at the organizational level
Coordination at the Organizational Level
  • Coordinated leadership across sectors - horizontal and vertical cultures and goals for patient care aligned to some extend
  • Disease management programs developed across sectors
  • Agreed stratification of patients between sectors ex. COPD FEV1% of expected magnitude limit at 50% changed to 30%
  • Use of identical measures including, diagnosis, diagnosis specific, general measures (BMI, smoking rates, etc., ), physical measures (senior fitness tests), quality of life; general and disease specific,
  • Knowledge sharing meetings
  • Teaching programs across sectors for nurses and therapists and for physicians
  • Sharing of patient information – referrals, summary
  • Follow-upeither in rehab. units or in local society,
coordination at the patient provider level
Coordination at the Patient – Provider level
  • Action plans - Agreements between patient and provider for goals of the rehabilitation
  • Patient education – activation of the patient
barriers to coordination
Barriers to Coordination
  • Non-aligned financial incentives between sectors
  • Culture differences between sectors
  • IT-systems not able to communicate sufficiently
  • …….
model for chronic care

Coordinated Leadership across Sectors

Model for Chronic Care

Patient / citizen

Toolbox

Bispebjerg Hospital

Copenhagen Municipality

  • Coordination supported by:
  • Clinical guidelines
  • Agreed stratification of patients
  • Identical quality assessment measures
  • Knowledge sharing meetings
  • Sharing of patient information
  • Follow-up

Leadership

Health professionals

Competences

Leadership

Health professionals

Competences

Patient / citizen

General Practitioners

Leadership

Health professionals

Competences

Patient / citizen

Coordinated Leadership across Sectors

the chronic care model
The Chronic Care Model
  • Some of the best practices in the chronic care model:
    • Leadership
    • Resources
    • Financial Incentives
    • Provider Feedback
    • Program Evaluation
    • Patient Action Plans
    • Patient Education
    • Guideline Training
    • Provider Alerts
    • Electronic health record
    • Defined Care Path
    • Risk Stratification
    • Registry
    • Follow-up
    • Inreach
    • Care Coordination
    • Team-Based Care
    • Cultural Competence

From Improving Chronic Illness Care

Ed Wagner, MD, Group Health Cooperative of Puget Sound

population management levels of care

Level 3

1-5%

Specialty

Care

Level 2

20-30%

Assisted Care for Multiple Risk Factor Management - Meds, Get to Goal, Lifestyle Change

Level 1 65-80%

PCP Care,,

Pharmacist

eCare, Web

Primary Care with Support -

Meds, Get to Goal, Lifestyle Change

Population Management Levels of Care

Advanced Disease

Complex Co-morbid Conditions

Complex Psychosocial Issues

Frail Elderly

  • Specialty MD Care
  • Coordination with case/care management, eCare
  • Need close surveillance of symptoms, medication titration, and intensive self-management education:
  • Not in control
  • Adherence problems/
  • Depression
  • Complex medication
  • regimen
  • Co-morbid conditions

Nurse or PharmD Care Management

MA with MD

eCare

  • Need Medications
  • Under Control
  • Lifestyle Changes
results
Results
  • Number of patients dived by diagnoses:
  • COPD
  • Type 2 diabetes
  • Heart failure
  • Balance problems
slide22
COPD
  • Se konklusionen..
rehabilitation units in the hospital and rehabilitation centres in the community
Rehabilitation units in the hospital and rehabilitation centres in the community

Patients at level 2 and some in 3 receive rehabilitation in the medical centre and patients at level 3 in the hospital

It is a demand that diagnoses and medical treatment are in place when patients are referred to rehabilitation

Activities in a rehabilitation centre:

  • Primary assessment, physical tests and quality of life tests
  • Physical Training
  • Smoking Cessation
  • Patient Education
  • Dietician Counselling
  • Psychosocial support
  • Planned follow-up
model for improved continuous care

Tværsektoriel ledelse

Model for improved continuous care

Patient / borger

Tool box

Bispebjerg Hospital

Københavns kommune

SCØ, andre kommunale aktører

Sammenhænge understøttes af:

Forløbsbeskrivelser

Stratificering

Monitorering

Videndelingsmøder

Informationsudveksling

Fastholdelse af effekt

Leadership

Health professionals

Competences

Ledelse

Personale

Faglighed

Patient / borger

Praktiserende læger

Ledelse

Personale

Faglighed

Patient / borger

Tværsektoriel ledelse

continuous care is supported by
Continuous care is supported by:
  • Forløbsbeskrivelser
  • Stratificering
  • Monitorering
  • Videndelingsmøder
  • Informationsudveksling
  • Fastholdelse af effekt
slide26
The National Strategy for Health Promotion and Prevention Focus onImprovements in eight Chronic Conditions

Prevalence rates of the most common chronic conditions

  • Diabetes 300.000
  • COPD 300.000
  • Coronary Heart Disease 200.000
  • Osteoporosis 300.000
  • Muscle skeletal disorders 800.000
  • Asthma and allergy 1.000.000
  • Cancer
  • Psychiatric diseases 100.000
the national strategy focus on improvements in eight chronic conditions
The National Strategy Focus onImprovements in Eight Chronic Conditions
  • Diabetes type 2
  • COPD
  • Cardiovascular diseases
  • Osteoporosis
  • Muscular and skeletal disorders
  • Allergy
  • Mental diseases
  • Preventable malignancies
background for the project
Background for the project
  • High and rising prevalence rates of chronic conditions
  • The structural reform and the new health act
new covered services in the primary care sector
New Covered Services in the Primary Care Sector
  • One-year follow-up in diabetes patients (type 1 and 2) including regularly controls, recording of diagnosis to IT system, ensure patients undergo recommended screenings

Experiences from DM will be used to develop benefit models in other chronic conditions such a COPD, asthma, CHF, depression etc.

continued new covered services in the primary care sector
Continued – New Covered Services in the Primary Care Sector
  • Prevention consultations related to life style factors such as tobacco use, alcohol, Physical activity nutrition, and Other risk factors and integrated counselling
  • Home visits to frail elderly once a year
  • Screening for depression
rehabilitation units in the hospital and rehabilitation centres in the community1
Rehabilitation units in the hospital and rehabilitation centres in the community

Patients are stratified to receive rehabilitation in the hospital if the belong to level 3 and patients at level 1 and 2 in the health center

It is a demand that diagnoses and medical treatment are in place when patients start rehabilitation

Activities in the rehabilitation centers:

  • Primary assessment, physical tests and quality of life tests
  • Physical Training
  • Smoking Cessation
  • Patient Education
  • Dietician Counselling
  • Psychosocial support
  • Planned follow-up