1. Practice management in co- morbid patients Jaime Correia de Sousa, MD, MPH Horizonte Family Health Unit Matosinhos Health Centre - Portugal Health Sciences School (ECS) University of Minho, Braga - Portugal

2. Objective At the end of this session the participants will:  Know why we need a new model of care for co-morbid problems  Value primary health care orientation in the care for chronic patients  Demonstrate the importance of clinical information systems in the management of co-morbidity  Recognise the need for a chronic care model  Value an approach to teaching and learning about co-morbidity management

3. Introduction  Most patients with chronic illnesses do not have a single, predominant condition.  Most have co-morbidity, the simultaneous presence of multiple chronic conditions.  Patients seek care for all of their co- morbidities, not just for a solitary, defining, major condition. Grumbach, 2003

4. Introduction  The majority of visits for care of both an indicator condition and its associated co- morbidities are made to primary care physicians.  What is needed is a model of care that addresses the whole person and integrates care for the person’s entire constellation of co-morbidities. Grumbach, 2003

5. Case Study Mrs B, head teacher of a primary school, 52 years old, overweight, has diabetes mellitus Doesn’t exercise; easily tired with small efforts; has a bad knee that keeps bothering her. The cholesterol level is high. Mrs B blood pressure is regularly checked and is within normal values. Mrs B has smoked all her adult life

6. Case Study Mrs B came to see her FP with a bad attack of bronchitis and was told by her doctor that she suspected she had asthma. The doctor prescribed an AB for the bronchitis and an inhaler for the asthma. Mrs B disagreed with her diagnosis of asthma and so took the antibiotics only. Within about 2 weeks she was much better and felt vindicated in her opinion about the asthma.

7. Case Study She continued to have difficulty climbing the stairs to the third floor at the top of the school but she put her difficulty down to the ravages of age, overweight and cigarettes. Her peak flow when measured by the doctor in the surgery was 240 litres per minute. It should have been 480 litres per minute.

8. Case Study In 5 m discuss in pairs: 1.Identify the major co-morbid health problems in this patient 2.The impact of a new diagnostic label and models of illness

9. Case Study To discuss later in the group: The most important tasks required to promote a better care for this patient Design a care package for this patient, considering the aims of care and the resources needed

10. A new model of care?  Basic Questions  Who should be involved in care?  What are our aims?  How should we organise care?

11. Basic Questions  What is the prevalence of co-morbidity among patients in family medicine?  How does this prevalence differ by the sex and age of the patient?  How does the prevalence differ between different conditions, particularly acute and chronic conditions?

12. Who should be involved in care? Patient Patient’s family PHC Team Family physicians Nurses Receptionists Hospital doctors and nurses Community Pharmacists Physiotherapists Psychologists Social workers etc

13. What are our aims?  Provide the best available care  Consider patient’s choices  Realistic aims with available logistics (staff, premises, funding)  Adequate management of the health systems’ resources  Prevention of health inequities  Reduce the economic burden of illness in the family

14. How should we organize care? Traditional Chronic Disease Specific Approach Chronic Care Model

16. Components of the Chronic Care Model  Community  Organisation of health care  Support self management  Design of delivery system  Decision support  Clinical information systems Lewis & Dixon, 2004

17. Components of the Chronic Care Model Community  Mobilise community resources to meet needs of patients Organisation of health care  Create a culture, organisation, and mechanisms that promote safe, high quality care Lewis & Dixon, 2004

18. Components of the Chronic Care Model Support self management  Empower and prepare patients to manage their health and health care Design of delivery system  Assure the delivery of effective, efficient clinical care and self management support Lewis & Dixon, 2004

19. Components of the Chronic Care Model Decision support  Promote clinical care that is consistent with scientific evidence and patient preferences Clinical information systems  Organise patient and population data to facilitate efficient and effective care Lewis & Dixon, 2004

20. Primary health care orientation  Reconciling the health needs of individual patients and the health needs of the community  Community or list based, personally and family oriented  Health promotion, prevention, cure, care and palliation and rehabilitation.  Covering the full range of health conditions  Co-ordination of care with other professionals  Pro-active

21. Patient centred model 1. Exploring both the disease and the illness experience 2. Understanding the whole person 3. Finding common ground regarding management 4. Incorporating prevention and health promotion 5. Enhancing the Doctor-Patient relationship 6. Being realistic Levenstein (1984)

22. Patient centred model

23. The importance of clinical information systems  Appointments systems  Enabling call and recall programmes  Repeat prescribing  Drug alerts (interactions, contraindications, secondary effects)  Decision support / expert-system  Supporting audit

24. Model of care for patients with co-morbid conditions Chronic care model Patient centred model Primary health care orientation Clinical Information System

25. Model of care for patients with co-morbid conditions Chronic care model Primary health care orientation Patient centred model Clinical Information System

26. THE TRANSFORMATION Care is Proactive Care delivered by a health care team Care integrated across time, place and conditions Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology Self-management support a responsibility and integral part of the delivery system Chronic Care Model Source: KPCMI Complete Forms Deal with Acute Attack of Disease Counsel re: Lifestyle Changes Review Labs Access Social/Other Services Reassure Diagnose General Referral Review/Adjust Rx and Tx Routine Preventive Care Modify and/or Negotiate Care Plans Review History Review Care Plan Talk with Family Reinforce Positive Health Behaviours Traditional Model SICKNESS CARE MODEL (Current Approach - Physician Centric) Consultation 10 minutes

27. So, how do we make this paradigm shift?  Start with better data extraction and information analysis to inform decisions  Implement case management for patients with highest burdens of disease  Implement guidelines for managing diseases and consider care co-ordination  Support self management and self care  Measure progress and achievement; and adjust process when necessary

28. Conclusions 1.Chronic illnesses are becoming the main activity of family physicians 2.Chronic diseases don’t exist isolated 3.Frequently, patients have more than one condition 4.A generalist approach is necessary 5.Shared care is important… but 6.We need a family practice based Chronic Care Model

29. Conclusion