Key note lecture at EGPRN meeting Ljubljana, May 2012

Quality Improvement in the Care of Chronic Disease in Family Practice: the contribution of education and research

Professor Janko Kersnik, MD, MSc, PhDHead of Research Department, Department ofFamily Medicine, Medical School LjubljanaHead of Family Medicine Department, Medical School Maribor, SloveniaPresident of EURACT

May 11, 2012 EGPRN Ljubljana 2

By the end of the presentation you will Know integrative care model Know traditional care models Know in which way finances and politicians

determine health care models Understand professional drive in

development of health care models Understand dilemmas in chronic care models Value continuous endeavours for better

patient care


Agenda of the presentation

1 Historical background Holistic approach Integrative care model Impact of science

2 Traditional care Episodic care Emergency room focus Breaking down to pieces

3 Money and politicians speak for themselves Waiving flags of

governments WHO declarations Financial constrains

4 Professional drive Family practice education Medical research Quality improvement


1 Historical background

Holistic approach Integrative care model Impact of science


Holistic approach – where does it come from?


Holistic approach – we have used it

Doctor’s visitJan Steen


(W)holistic approach

SFD are personal doctors, primarily responsible for the provision of comprehensive and continuing care…

SFD are trained in the principles of the discipline. One of six core competencies of a specialist family

doctor (SFD)*

*The European definitions of the key features of the discipline of general practice: the role of the GP and core competencies.Justin Allen, Bernard Gay, Harry Crebolder, Jan Heyrman, Igor Švab, and Paul Ram


Holistic approach – where does it lead us? SFD deals with health

problems in their physical, psychological, social, cultural and existential dimensions.

Dilemmas: how to practice, how to measure, how to pay, how to prove effectiveness, how to “compete” complementary and alternative medicine in holism…

“If God did not exist, it would be necessary to invent him.”*

*Voltaire


Integrative care model


Where do the demands for integrative care models come from? Before industrial revolution – an emperor need

for numerous and healthy armies to plunder other nations and protect own state.

Industrial revolution – an owner need for healthy workers for profit production.

Post-industrial era – a state need for consumers of abundance of products.

Philosophically – a human right for quality health care.


A comprehensive health care model based on Andrija Štampar public health paradigm Community based Active approach Team-work Health promotion, education and disease

prevention Early disease detection and treatment Continuous disease management and palliation

of patients on the lists


Andrija Štampar, Croatia

Public health expert of the Health Organization before Second World War

President of World Health Organization Assembly


A merge of political and health care theories in Yugoslavia One component of practical implementation of

Marxism is nationalisation of all resources, government becoming one big capitalist.

In this ideology health care becomes a buffer of social justice and a parading horse of the regime.

Practical consequences are universal coverage, good accessibility and availability, setting priorities, decentralisation and primary care focus.


Divergences in proclamations and practices WHO – 1978 Alma Ata

declaration on primary care

Health for all Primary health care

now more then ever

Eastern Europe – policlinics

Yugoslavia – subspecialisation of doctors in primary care clinics

Western Europe – specialist dominated care

UK - GP


Impact of science


Driving forces of science?

New knowledge New technologies New sub-

specialisations Breaking down a

human body to the smallest pieces

Who can fix a broken jar of humanism?


2 Traditional care

Traditional care Episodic care Emergency room focus Breaking down to pieces


Episodic care

Traditionally health care at all levels of care was episodic care of a problem encountered in a patient managed in the first and eventually few consecutive visits.

Emergence of a number of chronic diseases and technological possibilities to manage them for longer periods of time challenged episodic care and gave room for several models to tackle this issue.


Emergency room focus Illness are very unplanned events in human

lives. Technical advances in medicine made it

possible to cure many serious conditions if implemented in right time.

Several financial limitations made emergency care only care available for many patient groups.

Focus on emergency care in some countries shifts emphasis from usual family practice care to emergency care.


ER medicalisation


Outcomes of traditional BME teaching What would be a typical response of a student to

30-year old female patient presenting with following complaint:

“In the past 14 days several times I experienced pain in my chest, tightness in my neck and tingling in my left arm. Nearly every night this wakes me up in the middle of the night. I became worried as I might have died out of that.”


Breaking down to pieces

Necessary subspecialisation of medical profession brought us to situations, when each medical profession can only check its piece of human body, ignoring a person.


An urgent need for a comprehensive chronic care model? Wagner’s Chronic Care Model (broad conceptual

model),, chronic disease management → expanded chronic care model

Kaiser’s triangle (service delivery model), Evercare (service delivery model), Unique Care / Castelfields (service delivery model), NPDT collaborative eg. on COPD (service delivery

model), Expert Patient Programme (service delivery model), Pursuing Perfection (service delivery model), PARR tool developed by King’s Fund (service

delivery model).…


Canadian chronic care model


Canadian expanded chronic care model


UK chronic disease management model


3 Money and politicians speak for themselves Waiving flags of governments WHO declarations Financial constrains


Waiving flags of governments

Health care systems were waiving flags of governments when communicating with citizens in Eastern countries.

UK: Good chronic disease management offers real opportunities for improvements in patient care and service quality, and reductions in costs.


WHO declarations

Primary health now more than ever.


Financial constrains

There is always greater demand than resources available.

Cost-containment is one of the key elements of chronic disease models.

Computers are filled with better outcomes on indicators.

Chronic disease models are payer/government driven and may disrupt comprehensive family practice approach.


4 Professional drive

Family practice education Medical research Quality improvement


Family practice education

Performance = DOES

Competence = SHOWS HOW

Skills =KNOWS HOW

Knowledge = KNOWS Knows chronic care

models “Knows” chronicity

Possess skills for management of chronic

patientsPossess skills for

teamwork

Shows skills for management of chronic

patientsShows skills for teamwork

Performs chronic careWorks as a “team”


30-year old female patient

Student: acute coronary syndrome Theory: What are differential diagnoses? Practice: Direct observation of this

consultation Chinese proverb:

“I see and I remember.” Discussion Reflection Trying out


The European definitions of the key features of the discipline of general practice: the role of the GP and core competencies.Justin Allen, Bernard Gay, Harry Crebolder, Jan Heyrman, Igor Švab, and Paul Ram


Educational agenda

to provide longitudinal continuity of care as determined by the needs of the patient, referring to continuing and co-ordinated care management;

to co-ordinate care with other professionals in primary care and with other specialists;

to master effective and appropriate care provision and health service utilisation;

to communicate, set priorities and act in partnership; to promote health and well being by applying health

promotion and disease prevention strategies appropriately…


We know, but what do students say… “I was aiming to continue as surgeon and I was

blinded by big city FP, that FP do not perform a lot of medicine, but after working with your tutor in his practice, I saw, what could be provided to patients in FP…”

“You should continue to teach us communication skills, train to think from broader perspective and show us common patients’ problems…”

“After standing your tutorship in your practice, I feel confident to answer any question…”

“I changed my specialty training from anaesthesiology to FM, because I wanted to talk to people.”


Medical research on chronic care models Quality of care Clinical outcomes Resource use “While there is evidence that single or multiple

components of chronic care model can improve quality of care, clinical outcomes, and healthcare resource use, it remains unclear whether all components of the model, and the conceptualisation of the model itself, is essential for improving chronic care.”*

*Improving care for people with long-term conditions. http://www.improvingchroniccare.org/downloads/review_of_international_frameworks__chris_hamm.pdf


Quality improvement

The totality of evidence suggests that applying components of these models may improve quality of care for people with many different long-term conditions, but it remains uncertain which components are most effective or transferable.


IT in chronic care


Challenges in chronic care

Professionalism Ethical issues Team work Societal needs


Professionalism in chronic care What comes first? Am I forced by chronic care model to look

through a EURO or am I really following professional standards?

“Doctors shouldn’t be dependant on patients’ money.”


Ethical issues

Who comes first? Am I forced to neglect patient privacy and

autonomy to get quality data into my computer?

Doctors should have protected role in the society regarding keeping patient privacy.


Team work

Who leads my team? Am I prepared for shared decision making

with other professionals in my team and am I trained (interprofessionally) to do so without a conflicts for the best of our patients?

Teams should have a dynamic leadership depending on the patient issue, which the team deals with.


Societal needs

Who determines the foundation of the society?

Am I prepared to promote and keep core values of medicine against current political and economic winds of everyday practice if they are in conflict?

Doctors should be able to keep the pressure of unsolicited changes and to change their practices as appropriate.


Conclusions

One of the key points of our future endeavours in quality improvement are in meaningful translating high science to meaningful recommendations and translating some high-tech diagnostics and treatments to primary care level.

We should keep in mind that different models are coming and passing, but continuity of care of our (chronic) patients remains our continuous educational, research, quality in practice task.

Thank you very much for your attention!

Health & Medicine

Key note lecture at EGPRN meeting Ljubljana, May 2012