Implementing The Chronic Disease Management Framework - Shared Care - M Goulbourne - 29 Oct07

Moving from Operational Independence to Shared Care

Implementing the Chronic Disease

Prevention and Management Framework

Michelle Goulbourne

Global Perspectives on Chronic Disease Prevention and Management

2007 Conference Calgary, Alberta

October 29, 2007

DISCLOSURE:I have no real or potential conflict to disclose.

Overview

Chronic Disease in the Canadian Context

Implementing the Chronic Disease Prevention and Management Framework

in Canada

Regionalization

Discontinuities in Care

Impact on Performance

Implementation Experiences

Current State

Future State

The Road Towards Shared Care

Conceptual Model

Operational Model

Innovations Across Canada

Chronic Disease in the Canadian Context

In Canada chronic disease is a major cause of death and disability.

The leading four preventable diseases cardiovascular, cancer, respiratory and diabetes, cost an estimated 45 billion dollars annually.

Two out of three adult Canadians have one or more of the major risk factors associated with a preventable chronic disease.

(MOHLTC 2007)

Percent of adults with at least

one of six chronic conditions*

*Hypertension, heart disease, diabetes, arthritis, lung problems,

and depression

2004 Commonwealth Fund International Health Policy Survey

Chronic Disease Prevention and Management

Framework Goals

Nationally, Chronic Disease Prevention Management policy frameworks

have been based on the Chronic Care Model developed by the Group

Health McColl Institute for Healthcare Innovation in Seattle (Wagner et al. 2001).

Expanded versions of this model have been adopted because of their

focus on health promotion and a coordinated systems approach to disease

prevention and management are thought to provide important

opportunities for:

1. Reducing care discontinuities

2. Increasing prevention behaviors

3. Improving population health

4. Reducing cost

Implementing the CDPM framework for such long lasting sustainable

improvements is a challenge that requires a comprehensive system-wide,

multi-leveled approach to change.

Regional Deployment of the CDPM Framework

Regional deployment of the CDPM

framework requires that within each

region, local health care organizations:

Make systematic efforts to improve

prevention and management of chronic

disease.

Engage in delivery system design with

a focus on prevention, improved access,

continuity of care and flow through the

system.

Facilitate personal skills and self-management support among the population by

empowering individuals to build skills for healthy living and coping with disease.

Develop healthy public policy and supportive environments by creating and

implementing policies that will improve individual and population health and address

inequities.

(MOHLTC 2007)

Implementing the CDPM Framework

Literatures on strategy and organizational improvement suggest that we are not

so good at implementing what we design or at developing the new capabilities

the organization needs to survive and thrive – hence the need to become better

at designing and implementing organizations that can carry out our purposes

and provide settings where we can develop and thrive (Mohrman 2007).

Voices From The Field – Structural Issues

This CDPM framework, while insightful, shares no concrete information

organizations can draw upon which shows them how they can build bridges

to integrate organizational silos.

“Chronic disease programs in state public health agencies across the United States are

increasingly taking action to integrate activities across single-disease program lines.

The perceived benefits of program integration are the motivating force behind these

actions, but there is little documentation about how to integrate programs, what the

benefits are to program integration, and what barriers exist (Yach et al. 2004, p.

2616).”

Voices From The Field – Process Issues

Implementation is described as being a difficult process.

“Although the evidence base for some of these elements is incomplete, it is clearly a

comprehensive and promising way to conceptualize a path to better care for people

with chronic conditions. The problem is that we have no complete examples of an

implemented CCM and no specifics about the best care changes to make or the most

effective change process to use for implementing them…there is little or no information

about the relationship between the presence of CCM elements and indicators of care

quality (Solberg et al. 2006, p.311).”

Voices From The Field – Governance Issues

When organizations

have been tasked with

moving from single

disease to multiple

chronic disease

frameworks in the

absence of a central

coordinating structure,

they do not always

respond to

environmental

uncertainty by engaging

in collaborations.

The Reality: Divergent Values and Independent Action

Individual agencies may demonstrate territoriality and perceive a “loss of glory” (reluctance to share credit for achievements).

Resource costs involved in creating partnerships inhibit collaboration. Fear that collaborations may impact on independent fundraising activities.

Problems integrating programs as each program may be governed by different policies, service terms and day-to to-day operations - creating a “silo effect”.

Difficulties maintaining smaller or underfunded programs when they are integrated with established fully funded programs.

(Robinson, Farmer, Elliot and Eyles 2007)

Summary of CDPM Implementation Issues

Governance

Leadership to help build and support inter-organizational bridges.

Structure

Complete examples about implemented CDPM frameworks

Evidence to support all parts of the framework

Best, most effective, care changes

Relationship between CDPM elements and quality indicators

Process

How to integrate programs and services across diseases

How to build bridges across organizational silos

Across Canada, provincial efforts have paralleled global approaches in

trying to deal with health system uncertainty by establishing regional

care delivery organizations to create a more integrated, coordinated

and patient oriented healthcare delivery system.

Regionalization

Healthcare Regionalization in Canada

In Canada Regional Health Authorities (RHA‟s) exist as autonomous organizations.

Relationships with health care providers are characterized by accountability

agreements.

Are responsible for healthcare administration, planning and coordination within

specific geographic regions.

Have appointed or elected boards and are responsible for the funding and

delivery of community and institutional programs and services such as CDPM

within their regions (Kirby 2002).

Governance models under which provincial RHAs operate varies across provinces.

Within each province, the level of centralization may have implications for CDPM

activities and performance outcomes.

Incomplete Integration and Coordination

Despite sharing similar objectives, provincial health system transformations have

produced RHAs that differ in size, structure, scope of responsibility and

accountabilities .

While all RHAs manage hospital services, only some RHAs oversee laboratory

services, long-term care, home care and a variety of other services.

No provincial authority contracts physician services, manage prescription drug

programs or cancer services.

That these important care partners remain under the jurisdiction of provincial

and territorial portfolios has implications for provision of integrated service

delivery and coordinated CDPM care in the community.

Considerable local level variation exists in the way CDPM is implemented and the

levels of success attained.

Results Discontinuities in CDPM

CDPM progress is hampered by care discontinuities associated with poor system

integration and coordination.

1. Gaps in governance impede system capability to develop integrative policies

and local level partnerships across hospitals, physician and community health

stakeholders that will improve access to care, increase quality and health

service delivery.

2. Lack of technological integration results in a loss of information about patient

and family characteristics and histories.

3. Quality gaps in service integration and coordination remove opportunities for

communicative interactions and knowledge transfer between patients, families

and specific providers.

The impact of these discontinuities is evident

in our performance on global quality measures.

• Overall Ranking

• Information Technology

• Disease Management

• Physician Integration

Performance

Overall Performance Ranking*

SICKER ADULTS AUSTRALIA CANADA GERMANY

NEW

ZEALAND

UNITED

KINGDOM

UNITED

STATES

OVERALL RANKING (2007) 3.5 5 2 3.5 1 6

Quality Care 4 6 2.5 2.5 1 5

Right Care 5 6 3 4 2 1

Safe Care 4 5 1 3 2 6

Coordinated Care 3 6 4 2 1 5

Patient-Centered Care 3 6 2 1 4 5

Access 3 5 1 2 4 6

Efficiency 4 5 3 2 1 6

Equity 2 5 4 3 1 6

Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6

Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102

* 2003 Data Source: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the

Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy

Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard.

1.0-2.66

2.67-4.33

4.34-6.0

Country Rankings

Technology

Public Investment per Capita in

Health Information Technology (HIT) as of 2005

$192.79

$31.85$21.20

$4.93 $0.43

$0

$50

$100

$150

$200

United Kingdom

Canada Germany Australia United States

Source: The Commonwealth Fund, calculated from Anderson, G.F., Frogner, B., Johns, R.A., and Reinhardt, U.

“Health Care Spending and Use of Information Technology in OECD Countries,” Health Affairs, 2006.

Primary Care Doctors Use of Electronic Patient

Medical Records, 2006

9892 89

79

42

2823

0

25

50

75

100

NET NZ UK AUS GER US CAN

Percent of physicians

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

Primary Care Practices with Advanced

Information Capacity, 2006

*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions,

access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis,

medications, patients due for care.

Percent reporting 7 or more out of 14 functions*


8783

72

59

32

19

8

0

25

50

75

100

NZ UK AUS NET GER US CAN

Practice Use of Electronic Technology, 2006

Percent reporting

routine use of:AUS CAN GER NET NZ UK US

Electronic ordering

of tests65 8 27 5 62 20 22

Electronic

prescribing of

medication

81 11 59 85 78 55 20

Electronic access to

patients‟ test results76 27 34 78 90 84 48

Electronic access to

patients‟ hospital

records

12 15 7 11 44 19 40


Prevention

Patient Reports on Reminders for Preventive

Care, 2004

37 3844

49 50

0

25

50

75

AUS CAN NZ UK US

Percent of adults receiving preventive care reminders

2004 Commonwealth Fund International Health Policy Survey

65

8

28

61

9383

18

18

20

24

16

514

32

0

25

50

75

100

AUS CAN GER NET NZ UK US

Yes, using a manual system Yes, using a computerized system

Physicians Reporting Routinely Sending Patients

Reminder Preventive/Follow-Up Care Notice, 2006



Disease Management

* Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma,

emphysema, etc.), or depression.

Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).

6558 56

5045

37

0

50

100

CAN US NZ AUS UK GER

Percent of sicker adults with chronic conditions* whose

doctor gave plan to manage care at home

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 27

Sicker Adults Given Self-Management Plan, 2005

Received Recommended Care

for Chronic Condition, Sicker Adults, 2005

Percent received

recommended care:AUS CAN GER NZ UK US

Hypertension* 78 85 91 77 72 85

Diabetes** 41 38 55 40 58 56

* Blood pressure and cholesterol checked.

** Hemoglobin A1c and cholesterol checked, and feet and eyes examined.

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Physician Integration

Doctors‟ Reports of Care Coordination Problems,

2006

Percent saying their patients

“often/ sometimes”

experienced:


Records or clinical information

not available at time of

appointment

28 42 11 16 28 36 40

Tests/procedures repeated

because findings unavailable10 20 5 7 14 27 16

Problems because care was not

well coordinated across

sites/providers

39 46 22 47 49 65 37


Percent of Doctors Reporting Practice Is Well

Prepared to Care for Chronic Diseases, 2006


reporting “well

prepared”:


Patients with multiple

chronic diseases69 55 93 75 67 76 68

Patients with mental

health problems50 40 70 65 48 55 37


We can do better.

We must do better.

Implementation Experiences - Lessons Learned

Organizations in the health care community recognize that the successful implementation of CDPM initiatives across providers may require

Integrative governance

Local leadership

Cross-disease planning

Strategy

Multi-level partnerships

Knowledge sharing

Goal sharing

Information technology

Funding (Calnan et al. 2006, Robinson et al. 2007, Solberg et al. 2006, Wensing 2006).

Absence of integrative governance

and policy

Links all stakeholders groups.

Administrative and clinical

accountabilities (Goulbourne 2007).

Deployment of chronic disease care

models in community settings suggest

that organizations need help with:

the strategic operationalization of

integration dimensions ,

the relational coordination of

process factors (Robinson et al 2007;

Solberg et al 2006; Yach et al. 2004).

Successful Implementation - Prerequisites Barriers to Successful Implementations

The complex sustainable integrated care delivery system solutions we seek

require the implementation of „multisectoral, multidisciplinary and

multicomponent’ initiatives.

„Synergy, as it is manifested in the thoughts, relationships and actions within

the healthcare community, reflects the one aspect of collaboration that gives

partnerships that are able to achieve it a unique competitive advantage.‟

(Lasker et al. 2001)

Conceptual Model

Conceptual Model for CDPM Implementation

Horizontal Integration of Knowledge, Differentiation of Tasks and Services

(Goulbourne 2007)

Vertical

Integration

of

Structures

Shared goals,

a synchrony of efforts

and a synergy of effects.

A recent structured review of health care organizational interventions

revealed that benefits to clinical performance, patient outcomes and cost

reductions are empirically associated with transformations that include the

revision of professional roles (increased medical roles to nurses and a

widened scope of practice for pharmacists) and the use of computer systems

for knowledge management (Wensing et al. 2006).

Operational Model

Operational Model for CDPM – A Focus on Asthma

(Goulbourne 2007)

Shared care’ is the term that describes increasing the ability of…primary care

services, particularly GPs and pharmacists, to work more effectively… www.cambsdaat.org/treatment/shared_care.html

The term shared care is used to describe the joint provision of care, not

necessarily in the same place or at the same time, by members of the primary

care team and of a specialist team. Shared care schemes generally focus on

diabetes, asthma and antenatal care, but several other conditions such as

inflammatory bowel disease and hypertension might benefit from components

of the shared care approach.

Priority Areas: First round Evaluation of Shared Schemes (Department of Health 2003)

http://www.dh.gov.uk/en/Policyandguidance/Researchanddevelopment/A-

Z/Primaryandsecondarycareinterface/DH_4015532

Shared Care

http://www.cambsdaat.org/treatment/shared_care.html

http://www.dh.gov.uk/en/Policyandguidance/Researchanddevelopment/A-Z/Primaryandsecondarycareinterface/DH_4015532



Governance, Networks and Synergy

Governance is commonly recognized as

being an important component to

collaboration and functioning

partnerships.

The type of governance structure involved

in CDPM implementations is important.

Governance structures shape the nature and

composition of the partnerships, mode of

decision-making and impacts on the ways in

which partner perspectives, resources, skills

and knowledge are combined.

Governance is said to have a “profound

impact” of the level of synergy within the

partnership (Lasker, Weiss and Miller 2001, Touati et al.

2007).

Interior Health – Regional Health Authority, British Columbia Chronic Disease Prevention Strategy

Integrated Service Plan & Primary Care Collaborative

PHC/CDM Director, Advisory Committee, Change Management Team

Integration of clinical and community health

Negotiated physician involvement and participation via an alternate payment model

Link stakeholders and processes to provincial initiatives

Translate provincial innovations to regional and local levels

Established Chronic Disease Health Improvement Networks (6)

Multiple disease orientation

Interdisciplinary team

Patient education and self-management support

(Ockenden and Cheema 2004)

Shared Care

(EMR)

Acute Care

Primary Care

Ambulatory Care

Community Care

Physicians

NursesPharmacists

Patients

Collaborative Care:

Enhancing Clinical Service Network Link Overlap

Community based coalitions or sub-

networks may provide space where

organizations can develop levels of

synergy, exchange knowledge and

work together to pursue shared goals.

Stronger cooperative ties are more

likely to develop among small clusters

of organizations than among multiple

organizations in a broadly based

network (Provan and Sebatstian 1998).

Family Health Teams enhancing the

efficient use of health care resources.

Extra-Mural Program, New Brunswick

a provincial home health-care program

which is supported by a multidisciplinary

network of hospitals, health centres and

programs involved in health promotion,

education and the provision of

comprehensive health care services. (Goulbourne 2007)

Integrative

Technology

New Roles for Pharmacists in Primary Care

and Community Care Settings

New Roles and Collaborations across Acute, Primary and Community Health Care Settings.

Pharmacist deployed into new settings where their drug expertise is used to:

Enhance patient medication practices, physician prescribing and drug monitoring under treatment.

Enhance patient safety and optimal outcomes. Reduce the cost of patient non-adherence (readmissions), adverse drug events and after surgical intervention care.

Fraser Health Authority – Medication Management Program, British Columbia Commenced in 2005

Pharmacist performs home visits to assess medication regimens

Target → Seniors recently discharged from hospitals and clients high risk for drug related problems (6 or more medications)

Make recommendations to alleviate problems (prescribing pre-measured blister-packed medications, or eliminating unnecessary medications)

Pharmacists also perform academic detailing

Grand River Hospital Corporation and New Vision Family Health Team, Kitchener Ontario Commenced in 2006

Pharmacist has a shared care role across acute (.5FTE) and primary care (.5FTE) sectors

Pharmacist provides drug information to interdisciplinary clinical team

Collaborates in the development and deployment of chronic disease prevention and management programs

We will continue to do better.

We are doing better.

References

Goulbourne M. (2007). “Chronic Disease Prevention and Management: Examining regional

governance, network structures and outcomes.” (draft document)

Kirby, M. (2002). “The Health of Canadians: The Federal Role Final Report. “ Ottawa: The

Standing Senate Committee on Social Affairs, Science and Technology.

Lasker Roz D., Weiss Elisa S., et al. (2001). "Partnership Synergy: A Practical Framework for

Studying and Strengthening the Collaborative Advantage." The Millbank Quarterly 79(2): 179-

205.

Ministry of Health and Long Term Care. (2007). “Ontario‟s Chronic Disease Prevention and

Management Framework : Work of a Steering Committee. Presentation by Meera Jain,

February 2007, Grimsby Ontario.

Mohrman S.A. (2007). "Having Relevance and Impact: The Benefits of Integrating the

Perspectives of Design Science and Organizational Development." The Journal of Applied

Behavioral Science 43(1): 12-22.

Ockenden, G. and Cheema G. (2004) “Addressing the Need for Improvement. The IH Chronic

Disease Management Plan 2004-2006”. Government of British Columbia.

Provan Keith G. and Sebastian J.G. (1998). “Networks within Networks: Service Link Overlap,

Organizational Cliques, and Network Effectiveness." Academy of Management Journal 41(4):

453-463.

References Continued

Robinson Kerry, Farmer Tracy, et al. (2007). "From Heart Health Promotion to Chronic Disease

Prevention: Contributions of the Canadian Heart Health Initiative." Preventing Chronic Disease:

Public Health Research, Practice, and Policy 4(2): serial online.

Solberg Leif I., Crain Lauren A., et al. (2006). "Care Quality and Implementation of the Chronic

Care Model: A Quantitative Study." Annals of Family Medicine 4(4): 310-316.

Touati Nassera, Roberge Daniele, et al. (2007). "Governance, Health Policy Implementation and

the Added Value of Regionalization." healthcare Policy 2(3): 97-114.

Wagner E.H., Austin B.T., et al. (2001). "Improving chronic illness care: translating evidence into

action." Health Affairs 20(6): 64-78.

Wensing Michel, Wollersheim Hub, et al. (2006). "Organizational interventions to implement

improvements in patient care: a structured review of reviews." Implementation Science 1(2):

online journal.

World Health Organization. (2005). WHO Global Forum on Chronic Disease Prevention and

Control: Final report of the meeting convened in Ottawa, Canada 3-6 November 2004. N. D.

a. M. H. Department of Chronic Diseases and Health Promotion, World Health Organization and

the Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, WHO.

Yach Derek, Hawkes Corinna, et al. (2004). "The Global Burden of Chronic Diseases." Journal of

the American Medical Association 291: 2616-2622.

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Implementing The Chronic Disease Management Framework - Shared Care - M Goulbourne - 29 Oct07