1. Cadenza Conference Hong Kong Chronic Disease Management and its relevance for older people Steve Iliffe Professor of Primary Care for Older People, University College London Cadenza Symposium 2009 ~ Primary care & Older persons – Key to Medical & Social Integration

2. 2 Overview Scale of the problem Complexity & frailty Prevention Assessment Case Management Nurses as case managers Limitations of case management Outcomes Conclusions

3. 3 The scale of the problem The main challenge for primary care, worldwide Bodenheimer et al (2002) Improving primary care for patients with chronic illness JAMA; 288 (14) 1775-9 60% of hospital bed days in British hospitals 78% of all health care spending in the USA incidence of chronic diseases will double by 2030 Department of Health Improving chronic disease management London, 2004

4. 4 Not just long-term conditions…… Chronic disease in older people: Co-morbidity Complexity Frailty

5. 5 What are the chronic diseases? Cognitive impairment Obesity Diabetes Impaired mobility Cardiovascular diseases Depression

6. 6 Frailty Frailty heuristic: any 3 of: weakness tiredness poor endurance weight loss low levels of physical activity slow gait speed Fried et al (2004). Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol.A Biol.Sci.Med Sci., 59, 255- 263

7. 7 Is prevention of chronic disease possible ? Primary prevention: Exercise promotion Lawton et al (2008) The ‘Women’s lifestyle Study: two year randomised controlled trial of an exercise on prescription programme for women aged 40-74 recruited through primary care. BMJ Secondary prevention: Health Risk appraisal Harari et al (2008) Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice Age & Ageing; 37: 565-571 Tertiary prevention: Nurse-led health promotion Markle-Reid et al (2006) Health promotion for frail older home care clients. Journal of Advanced Nursing 54(3):381-95;

8. 8 Assessment of complexity & frailty We have a rich supply of instruments and tools for assessment of: Functional ability Falls risk Social network Affective state Cognitive function Nutritional status

9. 9 The clinical problem Assessment is relatively easy: the obstacles are lack of skills and lack of time Management is more difficult: we do not yet know what works, and it may be system-specific

10. 10 A solution Whole-system approaches to the management of chronic disease, ensuring: continuity of care improving patient outcomes and achieving efficient management of resources. (Wagner 1998, Dixon et al 2004)

11. 11 Dependency classification Three bands, with different levels of dependence on services: Level 1 ~ living with and self-managing the condition. Level 2 ~ at high risk from their condition, need active case management from multi-disciplinary teams. Level 3 ~ unstable and/or complex conditions needing proactive case management by designated key worker.

12. 12 Case Management 1.identification of individuals likely to benefit, 2.assessment of problems and need for services, 3.care planning of activities and services, 4.co-ordination and referral to implement the care plan, 5.and regular review, monitoring and adaptation of the care plan

13. 13 Nurses as case managers? Nurses already carry out and coordinate chronic disease management Chronic disease management ~ one of the three core roles of primary care nurses in the UK and USA.

14. 14 Types of nurse-led case management Traditional (community nursing, rehabilitation nursing) Led by social services/social work Disease and/or condition-specific Management of people with multiple conditions

15. 15 Are nurses essential? Availability Alternatives (Physiotherapists, occupational therapists, social workers?) Drennan et al (2008) Nurses as case managers : evidence from a survey in England. Report to National Institute of Health Research. System issues – how are health and social care organised?

16. 16 Chronic disease management remains problematic Evidence of limited effectiveness Reliance on traditional forms of patient education Poor linkages to other primary care disciplines Reliance on referrals

17. 17 Case management’s limitations 1.May not be wanted by older people 2.Independence and autonomy threatened by an intrusive care system 3.No unambiguous link between chronic condition and the need for health or social care De Lepeleire & Heyrman (2003) Is everyone with a chronic disease also chronically ill? Arch Public Health; 61: 161-176

18. 18 Outcomes of case management in different systems In North America CGA + systematic management reduces hospital admission rates Little impact on admission rates in the UK Fletcher, et al. (2004). Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial. Lancet, 364, 1667-1677 Little evidence of benefit to patients in terms of functional ability, in most studies

19. 19 Conclusions Management of chronic disease is the greatest challenge facing primary care Assessment methods are well developed Case management is developing Nurses may be best placed to be case managers in some systems The benefits of case management remain unclear, in some systems. A priority for research & development in primary care

20. 20 Thank you for listening s.iliffe@pcps.ucl.ac.uk www.evidem.org.uk