1. Continuous Care in Chronic Conditions Learning's from a project between Bispebjerg Hospital and Copenhagen Community “Improving Care in Europe and the US: Towards patient-centered, proactive and coordinated systems of care” Anne Frølich, MD, Ass. Professor, Department of Health Services Research, Bispebjerg Hospital, University of Copenhagen

2. Project members Jens Egsgaard Carsten Hendriksen Dorte Høst Helle Schnor Cecilia Ravn Jensen

3. Goals for the project 1.Improve care in chronic conditions focusing on continuity 2.Develop a model that support chronic care

4. Focus on Chronic conditions Recommendations for Improvement of Care in Chronic Conditions, National Board of Health, Year 2005 Prevalence rates of the most common chronic conditions COPD200.000 4% Type 2 DM 200.000 4% CHF200.0004% Muscle- 200.0004% Skeletal conditions Osteoporosis 300.0006%

5. National Board of Health – Publication with Recommendations Patient, Healthcare and Society

6. Reaching for a more Coordinated Healthcare System The Structure Reform: Reduced the 14 counties to 5 regions 278 Municipalities was reduced to 98 The new health act: Mandatory Healthcare Agreements to avoid fragmentation: Focus on discharge from hospital for weak elderly patients, agreements on social services for people with mental disorders and agreements on prevention and rehabilitation

7. The Local Government Reform

8. New Healthcare Act One of the major changes following the new health care act is transfer of the responsibility for rehabilitation and health promotion services from the regions to the municipalities

9. Coordination of Care Macro level State level, healthcare agreements between regions and municipalities Meso levelOrganizational level Micro level Patient-provider level

10. Methods and Material Copenhagen Municipality: 503.000 citizens Østerbro local area: 80.000 citizens Bispebjerg Hospital: 700 beds and 3.500 employees General practitioners: 57 GP’s, 50% in solo practices Conditions: COPD Type 2 diabetes Heart failure Balance problems

11. New Organization at the Municipality Level: Health Center

12. Rehabilitation in the hospital and at the municipality level – health center Activities in a rehabilitation unit: Primary assessment, physical tests and quality of life testsPrimary assessment, physical tests and quality of life tests Physical TrainingPhysical Training Smoking CessationSmoking Cessation Patient EducationPatient Education Dietician CounsellingDietician Counselling Psychosocial supportPsychosocial support Planned follow-upPlanned follow-up

13. Coordination at the Organizational Level Coordinated leadership across sectors - horizontal and vertical cultures and goals for patient care aligned to some extend Disease management programs developed across sectors Agreed stratification of patients between sectors ex. COPD FEV1% of expected magnitude limit at 50% changed to 30% Use of identical measures including, diagnosis, diagnosis specific, general measures (BMI, smoking rates, etc., ), physical measures (senior fitness tests), quality of life; general and disease specific, Knowledge sharing meetings Teaching programs across sectors for nurses and therapists and for physicians Sharing of patient information – referrals, summary Follow-up either in rehab. units or in local society,

14. Coordination at the Patient – Provider level Action plans - Agreements between patient and provider for goals of the rehabilitation Patient education – activation of the patient

15. Barriers to Coordination Non-aligned financial incentives between sectors Culture differences between sectors IT-systems not able to communicate sufficiently …….

16. Model for Chronic Care Leadership Health professionals Competences Health professionals Competences Health professionals Competences Leadership Copenhagen Municipality General Practitioners Bispebjerg Hospital Coordinated Leadership across Sectors Leadership Coordination supported by: Clinical guidelines Agreed stratification of patients Identical quality assessment measures Knowledge sharing meetings Sharing of patient information Follow-up Patient / citizen Coordinated Leadership across Sectors Toolbox Patient / citizen

17. Thank you for your attention!

19. The Chronic Care Model Some of the best practices in the chronic care model: –Leadership –Resources –Financial Incentives –Provider Feedback –Program Evaluation –Patient Action Plans –Patient Education –Guideline Training –Provider Alerts –Electronic health record –Defined Care Path –Risk Stratification –Registry –Follow-up –Inreach –Care Coordination –Team-Based Care –Cultural Competence From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound

20. Population Management Levels of Care Specialty Care Assisted Care for Multiple Risk Factor Management - Meds, Get to Goal, Lifestyle Change Primary Care with Support - Meds, Get to Goal, Lifestyle Change Level 1 65-80% PCP Care,, Pharmacist eCare, Web Level 2 20-30% Level 3 1-5% Specialty MD Care Coordination with case/care management, eCare Advanced Disease Complex Co-morbid Conditions Complex Psychosocial Issues Frail Elderly Need close surveillance of symptoms, medication titration, and intensive self-management education: Not in control Adherence problems/ Depression Complex medication regimen Co-morbid conditions Nurse or PharmD Care Management MA with MD eCare Need Medications Under Control Lifestyle Changes

21. Results Number of patients dived by diagnoses: COPD Type 2 diabetes Heart failure Balance problems

22. COPD Se konklusionen..

23. Rehabilitation units in the hospital and rehabilitation centres in the community Patients at level 2 and some in 3 receive rehabilitation in the medical centre and patients at level 3 in the hospital It is a demand that diagnoses and medical treatment are in place when patients are referred to rehabilitation Activities in a rehabilitation centre: Primary assessment, physical tests and quality of life testsPrimary assessment, physical tests and quality of life tests Physical TrainingPhysical Training Smoking CessationSmoking Cessation Patient EducationPatient Education Dietician CounsellingDietician Counselling Psychosocial supportPsychosocial support Planned follow-upPlanned follow-up

24. Model for improved continuous care Ledelse Personale Faglighed Health professionals Competences Personale Faglighed Ledelse Københavns kommune SCØ, andre kommunale aktører Praktiserende læger Bispebjerg Hospital Tværsektoriel ledelse Leadership Sammenhænge understøttes af: Forløbsbeskrivelser Stratificering Monitorering Videndelingsmøder Informationsudveksling Fastholdelse af effekt Patient / borger Tværsektoriel ledelse Tool box Patient / borger

25. Continuous care is supported by: Forløbsbeskrivelser Stratificering Monitorering Videndelingsmøder Informationsudveksling Fastholdelse af effekt

26. The National Strategy for Health Promotion and Prevention Focus on Improvements in eight Chronic Conditions Prevalence rates of the most common chronic conditions Diabetes300.000 COPD 300.000 Coronary Heart Disease200.000 Osteoporosis300.000 Muscle skeletal disorders800.000 Asthma and allergy 1.000.000 Cancer Psychiatric diseases 100.000

27. The National Strategy Focus on Improvements in Eight Chronic Conditions  Diabetes type 2  COPD  Cardiovascular diseases  Osteoporosis  Muscular and skeletal disorders  Allergy  Mental diseases  Preventable malignancies

28. Background for the project High and rising prevalence rates of chronic conditions The structural reform and the new health act

29. New Covered Services in the Primary Care Sector One-year follow-up in diabetes patients (type 1 and 2) including regularly controls, recording of diagnosis to IT system, ensure patients undergo recommended screenings Experiences from DM will be used to develop benefit models in other chronic conditions such a COPD, asthma, CHF, depression etc.

30. Continued – New Covered Services in the Primary Care Sector Prevention consultations related to life style factors such as tobacco use, alcohol, Physical activity nutrition, and Other risk factors and integrated counselling Home visits to frail elderly once a year Screening for depression

31. Rehabilitation units in the hospital and rehabilitation centres in the community Patients are stratified to receive rehabilitation in the hospital if the belong to level 3 and patients at level 1 and 2 in the health center It is a demand that diagnoses and medical treatment are in place when patients start rehabilitation Activities in the rehabilitation centers: Primary assessment, physical tests and quality of life testsPrimary assessment, physical tests and quality of life tests Physical TrainingPhysical Training Smoking CessationSmoking Cessation Patient EducationPatient Education Dietician CounsellingDietician Counselling Psychosocial supportPsychosocial support Planned follow-upPlanned follow-up