sgeneral principles of good chronic care

General Principles of good chronic care

Dr Samita AcharyaAssistant Professor

PAHS

Chronic conditions

• Any condition that requires ongoing adjustments by the affected person and interactions with the health care system.

Differences Between Acute and Chronic Conditions

ACUTE CHRONICBeginning Rapid Gradual

Cause Usually one Many

Duration Short Indefinite

Diagnosis Commonly accurate

Often uncertain

Diagnostic tests

Often decisive Often limited value

Treatment Cure common Cure rare

Differences Between Acute and Chronic Care Roles

ACUTE CHRONICRole of Professional

Select and conduct therapy

Teacher/coach and partner

Role of Patient

Lorig 2000

Follow orders Partner/ Daily manager

Chronic Illness in Nepal

• Despite annual spending of well amount of money by patients and significant advances in care, one-half or more of patients still don’t receive appropriate care.

• Gaps in quality care lead to thousands of avoidable deaths each year..

• Patients and families increasingly recognize the defects in their care.

Why are we doing so poorly?

• “The current care systems cannot do the job.”

• “Trying harder will not work.”

• “Changing care systems will.”

Why we are not efficient in managing chronic conditions?

• Rushed practitioners not following established practice guidelines.

• Lack of care coordination.• Lack of active follow-up to ensure the best

outcomes.• Patients inadequately trained to manage their

illnesses.

Why is it important to manage chronic illness well?

• Patients suffering from major chronic illnesses face many obstacles in coping with their conditions,its just not the medical care that often does not meet their needs but psychological support, and information.

What Patients with Chronic Illnesses Need

• A “continuous healing relationship” with a care team and practice system organized to meet their needs for:

Effective Treatment (clinical, behavioral, supportive), Information and support for their self-management, Systematic follow-up More intensive management for those not meeting targets, and Coordination of care across settings and professionals

CCM defines six elements whose coordination is necessary for quality disease management

• Community resources• Health system• Self management support• Delivery system design• Decision support• Clinical information systems

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformationSystems

Self-Management Support

Health System

Resources and Policies

Community Health Care Organization

Chronic Care Model

What distinguishes good chronic illness care from usual care?



PreparedPractice Team

Assessment of self-management goal attainment and confidence as well as clinical status

Adherence to guidelinesTailoring of clinical management by stepped protocol (Treat to

target)Collaborative goal-setting and problem-solving resulting in a

shared care planPlanning for active, sustained follow-up




How would you recognize aproductive interaction?

What characterizes an “informed, activated patient”?


They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.

What characterizes a “prepared” practice team?


Practice team and interactions with patientsorganized to help patients reach clinical targets and self-management goals..

Self-Management Support

Goal

To help patients take a more active role and be

more competent managers of their health and

healthcare.

Community Resources and Policies

Goal

To help patients access effective and useful services

and resources in the surrounding community.

Delivery System Design

Goal

To organize practice staff, schedules and other

systems to assure that all patients receive

planned, evidence-based care.

Decision SupportGoal

To assure that clinicians and other staff have the

training, scientific information and system

support to routinely provide evidence-based

(adhere to guidelines) and patient-centered care.

Clinical Information System

Goal

To assure that clinicians and other staff have ready

access to patient information on individuals and

populations to help plan, deliver and monitor

care.

Health Care Organization

Goal

To assure that practices within the organization

have the motivation, support and resources

needed to redesign their care systems.

FACTS AND FICTIONS1. Diabetes is the leading cause of adult blindness,

amputations and kidney failure. True or false?

________________________________________A. False. Poorly controlled diabetes is the leading cause of adult

blindness, amputations and kidney failure.

Symptom Cycle

Vicious Cycle

Disease

Tense musclesFatigue

Depression

Anger/Frustration/Fear

Stress/Anxiety

The Patient-Focused Approach

BELIEVE SELF-MANAGEMENT IS WORTHWHILE: The patient must feel there is hope and benefit in doing a good job.

KNOW WHAT TO DO. The patient must have a clear and achievable plan for self-management

General principles of good chronic care

• These principles can be used in managing many diseases and risk conditions.1. Develop a treatment partnerships with your

patients.2. Focus on your patient’s concerns and priorities.3. Use the 5 A’s:Assess,Advice,Agree,Assist and

Arrange4. Support patient self management.5. Organize proactive follow up

6.Involve “expert patients” ,peer educators and support staff in your health facility.

7.Link the patient to community- based resources and support.

8.Use written information-registers,treatment plan, treatment cards and written information for patients- to document, monitor and remind.

9.Work as a clinical team.10.Assure continuity of care.

Coordinated approach to chronic care

• To achieve good chronic care, community partners, health care team ,patients and families should always be prepared, informed and motivated.

Community partners

• Support patient goals and action plans.• Provide care and support to patient and family.• Provide resources to support patient self -

management, including peer support groups.• Function as treatment buddies.• Link with health care team and follow-up

periodically.(screening,health camp)• Advocate for policies to improve care

Health care team

• Elicit patient’s concerns.• Assess patient’s clinical condition, perform in

depth assessment ,diagnose.• Assess readiness to adopt indicated

treatments.• Exchange information about health risks.• Elicit patient’s goals for care.• Collaboratively agree upon treatment plan

Contd

• Refer for further diagnostic work and treatment plan, if indicated.

• Arrange for agreed follow-up.• Reinforce patient’s self-management efforts.• Involve peer educators/expert patients.• Link with community partners and follow up

periodically.

Patients and families

• Presents concerns.• Discuss goals with provider.• Negotiate a plan of care with provider /team• Self -monitor key symptoms and treatments.• Return for follow –up according to agreed

plan.

5A’s of chronic care consultation

• Assess – Asses patient’s goals for this consultation.– Asses patient’s clinical status, classify/identify relevant

treatment .– Asses risk factors that can lead disease or make it

worse– Asses patient’s knowledge, beliefs,concerns,and daily

behaviors related to chronic condition and treatment.– Asses that your patient ever tried a behavioral

modification or not .

Advise

• Use neutral and non-judgmental language.• Correct any inaccurate knowledge and

complete gaps in the patient’s understanding of conditions or risk factors and their treatments.

Agree

• Negotiate selection from the different options.• Agree upon goals that reflect patient’s priorities.• Ensure that the negotiated goals are:

– Clear – Measurable– Realistic– Under the patient’s direct control– Limited in number

Assist

• Provide a written or pictorial summary of the plan.

• Provide skills and tools to assist adherence.• Provide adherence equipment that is easy to

understand – You can arrange medicine box by day of week– Self monitoring tools( using calendar to remind

and record treatment plan)

• Address obstacles• Provide psychological support as needed

– Help patients to predict possible barriers to implementing the plan and to identify strategies to overcome them.

– If patient is depressed ,treat depression• Link to available support

– Friends,family– peer support groups– community services

Arrange

• Arrange follow-up to monitor treatment progress and to reinforce key messages.

• Record what happened during the visit.

Follow –up visit

• Assess– Compare assessment findings with those from

previous examination and discuss with patient.– Assess patient’s understanding of the treatment

plan.

• Assess patient’s adherence to the treatment plan(by asking, counting pills, checking pharmacy records).if there is adherence problem,its important to explore the reasons and obstacles to adherence.

• Acknowledge patient’s efforts and successes with self- management, even if they are limited.

• Advise – Repeat key information concerning the patient’s

condition and its treatment– Reinforce what patients need to self- manage

• Symptoms, when to change treatment or to seek care.• Treatment(why it is important, and adherence is

required)• How to monitor one’s own care.• How and where to seek support in the community.

• Agree – Negotiate changes in the plan as needed

• Assist– Discuss problems that occurred in adherence and

develop strategies to overcome them in future.• Arrange

– Arrange follow-up to monitor treatment progress and to reinforce key messages.

– Record what happened during the visit.

The Patient as Partner

Principles of CIS &DS

summary

• Whatever health services may offer, most of the day to day responsibilities for the care of chronic illness fall on patients and their families.

• Planners and organizers of medical care must recognize that health care will be most effective if it is delivered in collaboration with patients and their families.

• Health provider must practice evidence based medical treatment .

• To enable patients to play an active role in their care improve patients' knowledge and self management skills.

• Always apply 5A’s in your patient so that you can better– asses knowledge,beleifs and behavior– advice that has scientific evidence– agree on goals that are important to patients– assist by identifying barriers and strategies to overcome.– arrange continuity of care

•Thank you

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