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Presentation on the importance not to loose perspective on holistic and comprehensive apporach in managing pateints with chornic conditions.
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Quality Improvement in the Care of Chronic Disease in Family Practice: the contribution of education and research
Professor Janko Kersnik, MD, MSc, PhDHead of Research Department, Department ofFamily Medicine, Medical School LjubljanaHead of Family Medicine Department, Medical School Maribor, SloveniaPresident of EURACT
May 11, 2012 EGPRN Ljubljana 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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Agenda of the presentation
1 Historical background Holistic approach Integrative care model Impact of science
2 Traditional care Episodic care Emergency room focus Breaking down to pieces
3 Money and politicians speak for themselves Waiving flags of
governments WHO declarations Financial constrains
4 Professional drive Family practice education Medical research Quality improvement
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1 Historical background
Holistic approach Integrative care model Impact of science
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Holistic approach – where does it come from?
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Holistic approach – we have used it
Doctor’s visitJan Steen
May 11, 2012 EGPRN Ljubljana 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
May 11, 2012 EGPRN Ljubljana 8
Holistic approach – where does it lead us? SFD deals with health
problems in their physical, psychological, social, cultural and existential dimensions.
Dilemmas: how to practice, how to measure, how to pay, how to prove effectiveness, how to “compete” complementary and alternative medicine in holism…
“If God did not exist, it would be necessary to invent him.”*
*Voltaire
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Integrative care model
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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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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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Andrija Štampar, Croatia
Public health expert of the Health Organization before Second World War
President of World Health Organization Assembly
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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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Divergences in proclamations and practices WHO – 1978 Alma Ata
declaration on primary care
Health for all Primary health care
now more then ever
Eastern Europe – policlinics
Yugoslavia – subspecialisation of doctors in primary care clinics
Western Europe – specialist dominated care
UK - GP
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Impact of science
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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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2 Traditional care
Traditional care Episodic care Emergency room focus Breaking down to pieces
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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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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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ER medicalisation
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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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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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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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Canadian chronic care model
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Canadian expanded chronic care model
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UK chronic disease management model
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3 Money and politicians speak for themselves Waiving flags of governments WHO declarations Financial constrains
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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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WHO declarations
Primary health now more than ever.
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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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4 Professional drive
Family practice education Medical research Quality improvement
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Family practice education
Performance = DOES
Competence = SHOWS HOW
Skills =KNOWS HOW
Knowledge = KNOWS Knows chronic care
models “Knows” chronicity
Possess skills for management of chronic
patientsPossess skills for
teamwork
Shows skills for management of chronic
patientsShows skills for teamwork
Performs chronic careWorks as a “team”
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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
May 11, 2012 EGPRN Ljubljana 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
May 11, 2012 EGPRN Ljubljana 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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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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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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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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IT in chronic care
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Challenges in chronic care
Professionalism Ethical issues Team work Societal needs
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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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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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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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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.
May 11, 2012 EGPRN Ljubljana 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.
Thank you very much for your attention!
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