The Chronic Care Model as a vehicle
for the development of disease
management in Europe
Professor Cor Spreeuwenberg MD PhD Department Social Medicine
Faculty of Health, Medicine & Life Sciences Maastricht University
Content
Chronic Diseases
Some care approaches The Chronic Care Model US and Europe
Chronic Diseases
Aims of chronic care
prevention or delay of manifestation(s), where possible improved functioning of patients
- reducing symptoms and complications - prolonging lifespan
- improving quality of life - living independently
- according own needs, demands and preferences effective, efficient and safe health care delivery
Challenges of chronic care
access prevention & lifestyle integrated care
effective and efficient care (delivery) co-morbidity and multi-morbidity
tailoring to the needs of patients support of self-management
organization on different levels care management support
Do we treat all aspects effectively?
Results of systematic approach of people
with diabetes (N= 15.269) at T0, T12, T24
Lessons
Supporting practitioners to improve their medical skills seems to be more effective than paying attention to behavioural interventions
However
1. There are al lot of indications that most practitioners are
not skilled in applying behavioural interventions
2. Behavioural interventions require different approaches,
Approaches to improve chronic care
quality: integrated care
efficiency: disease management
outcomes: Chronic Care Model
Integrated care
- definition WHO (Gröne, Garcia-Barbero), 2001
- presented on IJIC-conference in Strassbourg, 2002
Integrated care is the bringing together of - inputs, delivery, management and
organization of services
- related to diagnosis, treatment, care, rehabilitation and health promotion.
Integration is a means to improve services in relation to access, user satisfaction and efficiency
Integrated care
(Kodner/Spreeuwenberg, 2002)
pragmatic definition: a step in the process of health systems
and health care delivery becoming more complete and comprehensive
contains a coherent set of methods and models on funding,
administrative, organizational, service delivery and clinical levels
designed to create connectivity, alignment and collaboration
within and between the cure/ care sectors
aims to enhance quality of life, consumer satisfaction and
system efficiency for patients with complex, long-term problems cutting across multiple services, providers and settings
Disease Management
- definition according to DMAA (2004)
a system (of) coordinated health care
interventions and communications (for) populations with conditions (in which) patient self-care efforts (are)
Disease management
background
originally an American concept one disease or health problem
feedback mechanism based on management information focus on efficiency more than on quality
population orientation
programmatic, systematic approach usually organized by a third party
2007: DMAA changed its name to
Care Continuum Alliance
care continuum includes strategies such as - health and wellness promotion
- disease management and - care coordination
Care Continuum Alliance promotes the role of
population health improvement in - raising the quality of care
- improving health outcomes and
- reducing preventable health care costs
Chronic Care Model: Aim
To improve functional and clinical outcomes
by relating processes on different levels
- - patient
- - practice team
- - organization responsible for the practice team - - health care system
Chronic Care Model: central issue
Creating a productive set of interactions between patient and practice team
“Informed, activated patient”
Application of principles of citizenship: patient as ´owner’ of the disease
understands principles of treatment able to make informed choices
able to cope with relevant technology knows signs/symptoms of complications knows who to call for support
active in preparing the next consultation
This is an intention, but keep in mind that not all patient are capable to act on this way!
Support of Self-management
- information and education of patients -
‘’Prepared and pro-active
practice team’’
Competence in clinical care, attitude, organization and communication
up-to-date knowledge and skills multi-disciplinary team
accessible and transparent
ready to support and to inform front- and back office
A
Network Information and Collaboration System
Patient
Personal Health Management
Personal Health Record Self management Patient education Protocols Processes Documentation Forms Population management Outcome management Decision support Screening Monitoring Benchmark rapports
General Practitioner Researcher
Practice nurse Medical specialist
Psychologist Dietician
Physiotherapist Podotherapist Geriatrist
Chronic Care Model:
related components or conditions
Community-level:. resources and policies
Health care delivery system-level
. health care organization . delivery system design
Practitioners/team-level
. clinical information systems . decision support
Evidence based strategies with high
success factors
Support of self-management
- preventive messages (web etc.) - self care education
Practice-level:
- disease registries to identify and track people - risk stratification models
- services in community settings
Europe: its health systems and
chronic care approaches
EU or related position
health care national issue nationalized and mixed public/private systems
various ways of organization
various approaches to market mechanisms various ways of chronic care management cf Ellen Nolte
Europe: disease management and
Chronic Care Model: general picture
much support for CCM
disease management initiatives
independent from nature health care system
disease management approaches compatible with CCM-model
discussions within governments about their role in implementing disease
management
Converging of American and
European chronic care approaches
stratification based on complexity and patient features continuum of care connectivity of personal, practice and system levels prevention - and lifestyle influencing
support of self-management
availability and interconnectiveness of information quality control and improvement mechanisms
Example: Stratification
US-Kaiser
NL
-
Matador
Permanente
Highly complex patients: Highly complex patients - Intensive case management - medical specialists
High risk patients: Moderate complex pts. - Disease Management - specialized nurses
Vast majority of pts: Non-complicated pts. - Supported self-care - practice nurses/GPs
2
1
3
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From challenges to changes
Implications: - organisational
- status and tasks of professionals - educational
- financial
Implications of change are significant, but the implications of not changing are even
Chronic Care Model (its principles)
as a vehicle for disease
management approach
DM-approach:
- provoked by new health legislation (2006)
- intended for all chronic diseases with important prevalence, starting with diabetes
- new entities, often regional embedded, which function as organizer and contractor
- most entities formed by GPs
- insurers supposed to set the rules
- entities subcontract concrete caregivers
Opportunities to integrate disease
management approach with CCM
- development of care standards
(how to use guidelines in daily practice) - subjects:
. diabetes, COPD, cardiovascular risk management . to be developed: heart failure, depression etc.
. newly written care standards take CCM as starting point
- Conclusion:
CCM can function as a vehicle to introduce a adapted way of disease management
Main messages
The CCM can be successfully combined with a diseases management
approach
Care patterns must be based on complexity of health problems and
readiness of patients for self-management
The nature of chronic diseases, together with the upcoming shortage of
staff, require a combined effort of all involved to develop powerful systems of self-management
Care standards based on CCM may function as a vehicle to start with a
European variant of disease management
DM-organizations that mainly serve the interest of regional practitioners,
may hinder the effectiveness and quality of chronic care in that region
