Looking for a new chronic care delivery model January 24th 2012 Irina Odnoletkova, Project Manager Innovations

Réunion - Date mio. leden Onafhankelijkheid Innovatie Klantgerichtheid Transparancie Solidariteit

Réunion - Date 3 Concern: sustainability of the health care system Economic crisis - Ageing population – Vision deficit

Réunion - Date 4

5 Chronic Care Model Elelments 1) delivery system re-design 2) self-management support 3) decision support based on the guidelines 4) clinical information systems 5) community recourses and policies 6) health systems focused on performance- oriented culture

Réunion - Date 6 Diabetes projects Leuven/Aalst ProjectLeuvenAalst Benchmark: USA total population GP participation32% (n=120)48% (n=40) Number of patients HbA1c<7% at baseline54%43% 57% Systolic blood pressure < 130 mmHG 50 %40% 45.5% LDL-C < 100mg/dl42%n.a. 46.5%

Réunion - Date 7 Why is getting to target important? each 1% reduction in HbA1c results into reduction of 21% for death risk related to diabetes, 14% for myocardial infarctions, 37% for microvascular complications over 10 years U.K. Prospective Diabetes Study (20-year /5.000 patients)

Réunion - Date 8 Why are many patients not at target? “Lack of timely appropriate medical decisions” “Not enough tools to support self-care (~90% of care)”

Réunion - Date 9 Quality Improvement Strategies Cochrane Effective Practice and Organisation of Care Group Audit and Feedback Case Management Team Changes EPR Clinician Education Patient Education Self-Management

Réunion - Date 10 What are the best QI Strategies? Case management (mostly by nurse): - Education - Coaching - Monitoring - Reminders - Treatment Adjustment (further research needed)

Réunion - Date 11 Diabetes Selfmanagement Education (DSME) “Impossible to be handled by the GP alone” (from “Aanbevelingen voor goede medische praktijkvoering”)

Réunion - Date 12 Drawbacks patient education in primary care Exclusion; Not consistent referral by GP’s; No standard for quality monitoring; High travel – and administration costs (~50%) Paper files; Upscalability???

Réunion - Date 13 Need for new care models PatientPayerCaregiver Pilot porjects => Evaluation => Business case => Implementation

Réunion - Date 14 Zorg TV pilot project ( )

Réunion - Date 15 Chain of self-management support effect Patient Behavior Disease Control Health Outcomes Patient Satisfaction Health Care Utilization Less Costs (???)

Réunion - Date 16 Dr Margarite J. Vale Clinical Associate Professor of Medicine The University of Melbourne Director, The COACH Program ©The COACH Program ® The evidence-based telephone delivered coaching program for patients with chronic disease

Réunion - Date 17 Research Questions Does diabetes self-management education by phone help the patients to achieve better results in T2D modifiable risk factors and therapy compliance? What is the cost-effectiveness COACH from the perspective of the health care system?

Réunion - Date 18 Conclusion Development of new care delivery model requires political will, organizational efforts, and a new culture of dialogue between the caregivers, the patients, the payers, the industry and the authorities. based on the principles of transparency and common values

Réunion - Date 19 l’Union Nationale des Mutualités Libres regroupe : de Landsbond van de Onafhankelijke Ziekenfondsen groepeert :