Presentation on the importance not to loose perspective on holistic and comprehensive apporach in managing pateints with chornic conditions.

1. Quality Improvement in the Care of
Chronic Disease in Family Practice: the
contribution of education and research
Professor Janko Kersnik, MD, MSc, PhD
Head of Research Department, Department of
Family Medicine, Medical School Ljubljana
Head of Family Medicine Department, Medical School
Maribor, Slovenia
President of EURACT

2. By the end of the presentation you will
 Know integrative care model
 Know traditional care models
 Know in which way finances and politicians
determine health care models
 Understand professional drive in
development of health care models
 Understand dilemmas in chronic care models
 Value continuous endeavours for better
patient care
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3. Agenda of the presentation
 1 Historical background  3 Money and politicians
 Holistic approach speak for themselves
 Integrative care model  Waiving flags of
 Impact of science governments
 WHO declarations
 2 Traditional care
 Financial constrains
 Episodic care
 Emergency room focus
 4 Professional drive
 Breaking down to pieces  Family practice education
 Medical research
 Quality improvement
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4. 1 Historical background
 Holistic approach
 Integrative care model
 Impact of science
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5. Holistic approach – where does it come
from?
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6. Holistic approach – we have used it
Doctor’s visit
Jan Steen
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7. (W)holistic approach
 SFD are personal doctors, primarily responsible for
the provision of comprehensive and continuing
care…
 SFD are trained in the principles of the discipline.
 One of six core competencies of a specialist family
doctor (SFD)*
*The European definitions of the key features of the discipline of general practice:
the role of the GP and core competencies.
Justin Allen, Bernard Gay, Harry Crebolder, Jan Heyrman, Igor Švab, and Paul
Ram
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8. Holistic approach – where does it lead us?
 SFD deals with health  “If God did not exist,
problems in their physical, it would be
psychological, social, necessary to invent
cultural and existential him.”*
dimensions.
 Dilemmas: how to
practice, how to measure,
how to pay, how to prove
effectiveness, how to
“compete” complementary
and alternative medicine
in holism…  *Voltaire
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9. Integrative care model
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10. Where do the demands for integrative care
models come from?
 Before industrial revolution – an emperor need
for numerous and healthy armies to plunder
other nations and protect own state.
 Industrial revolution – an owner need for healthy
workers for profit production.
 Post-industrial era – a state need for consumers
of abundance of products.
 Philosophically – a human right for quality health
care.
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11. A comprehensive health care model based
on Andrija Štampar public health
paradigm
 Community based
 Active approach
 Team-work
 Health promotion, education and disease
prevention
 Early disease detection and treatment
 Continuous disease management and palliation
of patients on the lists
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12. Andrija Štampar, Croatia
 Public health expert of
the Health Organization
before Second World
War
 President of World
Health Organization
Assembly
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13. A merge of political and health care
theories in Yugoslavia
 One component of practical implementation of
Marxism is nationalisation of all resources,
government becoming one big capitalist.
 In this ideology health care becomes a buffer of
social justice and a parading horse of the
regime.
 Practical consequences are universal coverage,
good accessibility and availability, setting
priorities, decentralisation and primary care
focus.
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14. Divergences in proclamations and
practices
 WHO – 1978 Alma Ata  Eastern Europe –
declaration on primary policlinics
care  Yugoslavia –
 Health for all subspecialisation of
 Primary health care doctors in primary care
now more then ever clinics
 Western Europe –
specialist dominated
care
 UK - GP
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15. Impact of science
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16. Driving forces of science?
 New knowledge
 New technologies
 New sub-
specialisations
 Breaking down a
human body to the
smallest pieces
 Who can fix a broken
jar of humanism?
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17. 2 Traditional care
 Traditional care
 Episodic care
 Emergency room focus
 Breaking down to pieces
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18. Episodic care
 Traditionally health care at all levels of care
was episodic care of a problem
encountered in a patient managed in the first
and eventually few consecutive visits.
 Emergence of a number of chronic diseases
and technological possibilities to manage
them for longer periods of time challenged
episodic care and gave room for several
models to tackle this issue.
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19. Emergency room focus
 Illness are very unplanned events in human
lives.
 Technical advances in medicine made it
possible to cure many serious conditions if
implemented in right time.
 Several financial limitations made emergency
care only care available for many patient
groups.
 Focus on emergency care in some countries
shifts emphasis from usual family practice
care to emergency care.
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20. ER medicalisation
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21. Outcomes of traditional BME teaching
 What would be a typical response of a student to
30-year old female patient presenting with
following complaint:
 “In the past 14 days several times I experienced
pain in my chest, tightness in my neck and
tingling in my left arm. Nearly every night this
wakes me up in the middle of the night. I
became worried as I might have died out of
that.”
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22. Breaking down to pieces
 Necessary
subspecialisation of
medical profession
brought us to situations,
when each medical
profession can only
check its piece of
human body, ignoring a
person.
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23. An urgent need for a comprehensive
chronic care model?
 Wagner’s Chronic Care Model (broad conceptual
model),, chronic disease management → expanded
chronic care model
 Kaiser’s triangle (service delivery model),
 Evercare (service delivery model),
 Unique Care / Castelfields (service delivery model),
 NPDT collaborative eg. on COPD (service delivery
model),
 Expert Patient Programme (service delivery model),
 Pursuing Perfection (service delivery model),
 PARR tool developed by King’s Fund (service
delivery model).…
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24. Canadian chronic care model
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25. Canadian expanded chronic care model
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26. UK chronic disease management model
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27. 3 Money and politicians speak for
themselves
 Waiving flags of governments
 WHO declarations
 Financial constrains
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28. Waiving flags of governments
 Health care systems were waiving flags of
governments when communicating with
citizens in Eastern countries.
 UK: Good chronic disease management offers
real opportunities for improvements in patient
care and service quality, and reductions in costs.
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29. WHO declarations
 Primary health now more than ever.
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30. Financial constrains
 There is always greater demand than
resources available.
 Cost-containment is one of the key elements
of chronic disease models.
 Computers are filled with better outcomes on
indicators.
 Chronic disease models are
payer/government driven and may disrupt
comprehensive family practice approach.
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31. 4 Professional drive
 Family practice education
 Medical research
 Quality improvement
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32. Family practice education
Performs chronic care
Performance = Works as a “team”
DOES
Shows skills for management
Competence =
of chronic patients
SHOWS HOW Shows skills for teamwork
Skills = Possess skills for
KNOWS HOW management of chronic
patients
Knowledge =
Possess skills for teamwork
KNOWS Knows chronic care
models
“Knows” chronicity
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33. 30-year old female patient
 Student: acute coronary syndrome
 Theory: What are differential diagnoses?
 Practice: Direct observation of this
consultation
 Chinese proverb:
“I see and I remember.”
 Discussion
 Reflection
 Trying out
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34. The European definitions of the key features of the discipline
of general practice: the role of the GP and core competencies.
Justin Allen, Bernard Gay, Harry Crebolder, Jan Heyrman, Igor
Švab, and Paul Ram
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35. Educational agenda
 to provide longitudinal continuity of care as
determined by the needs of the patient, referring to
continuing and co-ordinated care management;
 to co-ordinate care with other professionals in
primary care and with other specialists;
 to master effective and appropriate care provision
and health service utilisation;
 to communicate, set priorities and act in partnership;
 to promote health and well being by applying health
promotion and disease prevention strategies
appropriately…
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36. We know, but what do students say…
 “I was aiming to continue as surgeon and I was
blinded by big city FP, that FP do not perform a lot
of medicine, but after working with your tutor in his
practice, I saw, what could be provided to patients in
FP…”
 “You should continue to teach us communication
skills, train to think from broader perspective and
show us common patients’ problems…”
 “After standing your tutorship in your practice, I feel
confident to answer any question…”
 “I changed my specialty training from
anaesthesiology to FM, because I wanted to talk to
people.”
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37. Medical research on chronic care models
 Quality of care
 Clinical outcomes
 Resource use
 “While there is evidence that single or multiple
components of chronic care model can improve
quality of care, clinical outcomes, and healthcare
resource use, it remains unclear whether all
components of the model, and the
conceptualisation of the model itself, is essential
for improving chronic care.”*
*Improving care for people with long-term conditions.
http://www.improvingchroniccare.org/downloads/review_of_international_frameworks__chris_hamm.pdf
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38. Quality improvement
 The totality of evidence suggests that
applying components of these models may
improve quality of care for people with many
different long-term conditions, but it remains
uncertain which components are most
effective or transferable.
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39. IT in chronic care
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40. Challenges in chronic care
 Professionalism
 Ethical issues
 Team work
 Societal needs
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41. Professionalism in chronic care
 What comes first?
 Am I forced by chronic care model to look
through a EURO or am I really following
professional standards?
 “Doctors shouldn’t be dependant on patients’
money.”
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42. Ethical issues
 Who comes first?
 Am I forced to neglect patient privacy and
autonomy to get quality data into my
computer?
 Doctors should have protected role in the
society regarding keeping patient privacy.
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43. Team work
 Who leads my team?
 Am I prepared for shared decision making
with other professionals in my team and am I
trained (interprofessionally) to do so without a
conflicts for the best of our patients?
 Teams should have a dynamic leadership
depending on the patient issue, which the
team deals with.
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44. Societal needs
 Who determines the foundation of the
society?
 Am I prepared to promote and keep core
values of medicine against current political
and economic winds of everyday practice if
they are in conflict?
 Doctors should be able to keep the pressure
of unsolicited changes and to change their
practices as appropriate.
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45. Conclusions
 One of the key points of our future endeavours in
quality improvement are in meaningful translating
high science to meaningful recommendations and
translating some high-tech diagnostics and
treatments to primary care level.
 We should keep in mind that different models are
coming and passing, but continuity of care of our
(chronic) patients remains our continuous
educational, research, quality in practice task.
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46. Thank you very much for
your attention!