Applying the Chronic Care Model to Health System Redesign in Uganda Godfrey Kayita STD / AIDS Control Program - MOH Uganda Humphrey Megere URC/USAID Healthcare Improvement Project Kedar Mate Institute for Healthcare Improvement Suzanne Gaudreault URC/USAID Healthcare Improvement Project 7/24/2015 1
Seminar Outline The Chronic Care Model: Why it is needed and its application at the facility level Suzanne Gaudreault Chronic Care at the national level Kedar Mate The challenge of providing care for Chronic Diseases like HIV/AIDS, TB, DM, HTN and other chronic conditions in Uganda 2010 Chronic Care Conference in Kampala Godfrey Kayita Implementation of the Chronic Care Model in Uganda Humphrey Megere 2
The Chronic Care Model: Why it is Needed and its Application at the Facility Level Suzanne Gaudreault URC/USAID Healthcare Improvement Project 3 7/24/2015 3
Acute vs. Chronic Care Acute Chronic Visit frequency When sick Varies by illness Visit content Provider-patient Relationship Single Assessment, Diagnosis & Treatment Less important Recurring assessments, Ongoing treatment, Lifestyle/prevention Communication, trust very important Self-management Limited Extensive Recordkeeping Family & community support Long term record not necessary Short-term Long term record essential Lifelong
Why do health systems need to be redesigned? Low resource health systems are designed for Acute Care Treating chronic illnesses in systems designed for acute care contributes to: Poor coverage Poor retention in care Poor self-management of disease Poor clinical outcomes Demotivated health workers Chronic Illness Poor health of people with chronic conditions; psychosocial and economic consequences, etc.
The Chronic Care Model 6
Self-Management Ability of patients with chronic illnesses, in collaboration with their health care providers and other support structures such as family and community, to manage the symptoms, treatment, lifestyle behavior changes, and the many physical and psycho-social challenges that they face each day PATIENT EMPOWERMENT
What do empowered patients do to self-manage? Learn about their disease Know the consequences of poor treatment adherence Seek medical care and advice when needed Communicate effectively with health workers Actively partner with providers in decision-making Self-monitor symptoms and follow treatment directions Practice health-enhancing behaviors Use family, peer, and community support resources Work to maintain emotional and psychological balance
7 Basic Components of Self- Management Support 1. Provide information about the chronic condition 2. Encourage active participation in managing the condition 3. Teach skills specific to the condition 4. Negotiate actions to achieve and maintain good health 5. Teach problem-solving skills 6. Address emotional impact of the condition 7. Facilitate use of supportive community resources 9 Tom Bodenheimer, Helping Patients Help Themselves: How to implement Self-Management Support www.chcf.org, 2010
Self Management Support in Chronic Illness Care Continuous Healing Relationship Informed Activated Patient Productive Interactions Prepared Proactive Team
Community Strengthen community linkages to facilities: Community and Faith Based Organization Village Health Team (VHT) Support groups Income-generating groups Mosques and churches Others Strengthen self-management support activities in community structures including support groups Lobby for health policy and system changes 11
Delivery System Design Define roles and definitions of HCWs Community workers and peer supporters/expert patients, and other cadres on health care teams Introduce Triage Planned patient interactions Adapt home-based care to the chronic care needs of HIV patients 12
Decision Support Evidence-based guidelines embedded into documentation Provider education National guidelines Job aids Specialist and primary care expertise 13
Clinical Information System Unified documentation Patient subpopulation registries Reminders for patients and HCWs Monitoring and Evaluation 14
System Redesign for Chronic Care at the National Level Kedar Mate Institute for Healthcare Improvement 15 7/24/2015 15
Design for Chronic Care at a National Level All systems provide acute to chronic care Acute care = Premium on time; provider-driven Chronic care = Premium on partnership; patientdriven; provider-supported Most health systems start with emergency response / acute care Countries needs guidance both in rich & poor alike
Methods Reviewed existing frameworks: WHO Health Systems Framework MacColl Institute Chronic Care Model WHO Innovative Care for Chronic Conditions
WHO Adaptation Chronic Care Framework 2002
Self Management Delivery system design Clinical Information Decision Support Community Resources & Policies
Macro-level Change Ideas CCM Elements Self Management Support (SMS) Decision Support (DS) Delivery System Design Clinical Information Systems (CIS) Community Resources and Policies Human Resources Make available staff whose main responsibility is SMS (existing cadre or new cadre) Pre-service training on SMS Career development plan for those involved in SMS Supervision and mentoring for SMS Staff hotlines to answer difficult clinical questions Training and support to use decision supports Focus on multi-disciplinary team work Team based training Curricula in professional schools focus on team work and chronic care Redefine correct staffing mix Train and support staff to manage CIS (new or existing cadre) Form, train and support community based health workers (CHW) Policies to allow CHW to provide support WHOHSS Building Blocks Information Technology Financing (Purchasing) Changing medical records to include longitudinal information on self management Provide resources to train and support SMS staff Procurement and distribution of SM materials (e.g. pill boxes, home glucometers) Develop and distribute guidelines and job aids Include reminders in IT system Allocate funds for decision support IT designed to work in team setting Developed to meet needs or patients and providers Allocate funds to redesign delivery systems to meet needs of patients with chronic conditions Develop CIS system for chronic conditions care Fund CIS system for chronic conditions care Develop information system that can be used in community and links between community and facility Fund community supports (staff, transport, materials, patient resources) Build counselling areas in facilities Supply Chain Procure and distribute SM materials (e.g. pill boxes, home glucometers) Procure and distribute guidelines, job aids and other decision support tools Redesign for reliable drug and supplies availability Procure and distribute CIS materials Include community sites as distribution points Leadership & Governance Involvement of patients in leadership and governance Modelling of good relationship between patients and providers Professional societies involved in DS tool development Patient advocates involved in DS tool development Modelling of teamwork by professional organizations, government, senior managers Encourage use of data by patients and providers as well as central MoH Involve community in leadership roles Increase focus on demand creation Professional organizations embrace SMS Leadership in other sectors to incentivize healthy behaviours
Example #1: Changes to the health system necessary to deliver self-management services Human resources Make available staff whose main responsibility is SMS (existing cadre or new cadre expert patient) Pre-service training on SMS Career development plan for those involved in SMS Supervision and mentoring for SMS Information technology SM data included in patient records Longitudinal medical record that tracks SM data Finance Supply chain Leadership Payment reform: Insurance schemes encourage use of SMS Private counselling rooms in facilities SM supplies included in procurement Pill boxes SM Diaries SM home mgmt decision support Leaders modelling increased involvement of patients SMS recognized by professional organizations Leadership in other sectors emphasize SMS behaviors
Example #2: Changes to the health workforce to deliver integrated CC services Self Management Support (SMS) Make available staff whose main responsibility is SMS (existing cadre or new cadre expert patient) Pre-service training on SMS Career development plan for those involved in SMS Supervision and mentoring for SMS Decision Support (DS) Staff hotlines to answer difficult clinical questions Training and support to use decision supports CC Job Aids/ Tools/ Checklists Delivery System Design Focus and create multidisciplinary teams; empanel pts Curricula in professional schools focus on team work and chronic care Redefine correct staffing mix Clinical Information Systems (CIS) Train and support staff to manage CIS with longitudinal records (new or existing cadre) Development partners change CIS to manage chronic disease Community Resources and Policies Form, train and support community based health workers (CHW) Policies to allow CHW to provide support
Summary All countries battle transitions from acute diagnosis and output driven systems to chronic management and outcomes driven systems Broad coalitions will be necessary All models are wrong, some are useful» Box, George E. P.; Norman R. Draper (1987). Needs more testing and prototyping
The Challenge of Providing Care for Chronic Diseases in Uganda and the 2010 Chronic Care Conference in Kampala Godfrey Kayita STD / AIDS Control Program - MOH Uganda 25 7/24/2015 25
Uganda Background Population: 32,369,558 Pop. Growth Rate ~ 2.69% Per capita ~ $490 Per capita (Health) ~ $12 (Abuja $15) Life Expectancy ~ 52.72 PLHIV ~1,200,000 [adults] PLHIV ~100,000 [children] Adult Prev. ~ 6.4 % Children Prev. ~ 1.5% TB/HIV prev. ~ 56% HIV/TB prev. ~12% 26 26
Current status of chronic care in Uganda WHO guidelines-based IMAI and IMCI guidelines used for adult and pediatric care present primary care chronic management approach to HIV Apart from HIV and TB care, true chronic disease care is limited to regional hospitals and a few district hospitals (sickle cell disease, diabetes, hypertension, cardiac disease) Health care training and service delivery continue to focus on infectious and parasitic diseases
May 2010 Uganda Chronic Care Design Meeting: Objectives Identify elements of the Chronic Care Model applicable to Uganda Develop an approach to integrating these elements in a prototype district Make MoH recommendations for Chronic Care 28
Uganda MOH Recommendations on Chronic Care: 1. Demonstrate commitment to a health system for chronic as well as acute illnesses: Prioritize resources (material and human) Communicate commitment to improving CC care 2. Develop and test a model based on chronic care principles using HIV as an example: Demonstration projects 3. Strengthen & support existing health system entities: Village Health Teams Expert Patients Health Unit Management Committees
Uganda MOH Recommendations 4. Support health care providers, patients, and communities to carry out roles effectively: Work as teams to deliver chronic health care and prevention Community education about prevention and CC care Partner with health education schools to sustain this effort Chronic Care Curriculum 5. Develop a Health Information System which: integrates all levels and types of care into one health record allows providers to see the health outcomes of their patients generates accurate data to evaluate and improve programs
Implementation of the Chronic Care Model in Uganda Humphrey Megere URC/USAID Healthcare Improvement Project 31 7/24/2015 31
Buikwe District Central region 407,100 population Facilities 5 hospitals 10 Health Centre III Kampala Buikwe
Baseline assessment at Nyenga Hospital
Baseline results from Uganda: Elements of the Chronic Care Model 100 Patient self-management % o f p a t i e n t s 90 80 70 60 50 40 30 20 10 0 Pt know drug names Pt know treatment is life long Pt aware of side effects Pt can get support from family Pt can get help from the facility %HIV %TB %DM %HTN
Facility level care systems to improve self management F a c i l i t i e s 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Patients with HIV and TB have special days and special health workers. For me when I come, I line up for long with the other patients and I don t get time to discuss my problems. I just get drugs and I go. I want to know why I get injections and not tablets like HIV patients. Diabetic patient of Nkokonjeru \ Hospital 0% dedicated staff for patient education dedicated staff to help patients solve problems HIV TB DM HTN separate stable patients from the sick We see HIV patients every month. But patients with diabetes come when they are sick. Health provider of Buikwe hospital
Availability of patient monitoring tools at facilities 100 80 f a c i l i t i e s 60 40 20 0 HIV TB DM HTN individual longitudinal patient records disease specific registries 36
Availability of mechanisms to support good clinical decisions 100% 90% 80% f a c i l i t i e s 70% 60% 50% 40% 30% 20% 10% 0% HIV TB DM HTN guidelines available use reminders SOPs available access specialist
Chronic Care Model Prototype: Progress to Date Baseline assessment 1 st Improvement Collaborative Learning Session to introduce Chronic Care Model. 1 st coaching visit: coaching teams composed of HCI, MOH, and DHT (district health teams) members Logistics support to sites (counter books and box files to help in improving records) Spread diabetes medical record being used at one hospital to all the other sites.
Example Changes/Interventions: Self-Management Knowledge Health education talks at facilities Handouts to patients on diabetes Skills Patient goal-setting introduced Motivation Patients participate in clinic activities
Interventions: Delivery system design All the sites made flow charts Some sites assigned Self- Management Support role to specific staff Some sites changed patient seating arrangement New flow chart at Buikwe Hospital
Interventions: Clinical information system All sites have introduced registers for specific for Diabetes and Hypertension Kawolo Hospital has introduced longitudinal files for diabetic patients Buikwe Hospital is providing free treatment books to patients Back of HIV care record being used to document Self- Management interventions New diabetic register
Decision Support Tools
Other changes Formation of Chronic Care QI teams Reduction of user fees for patients with Diabetes and Hypertension (HIV care was already reduced or free)
Way forward Focus on HIV initially but encourage spill over to other chronic diseases Re-focus on on Self Management Support: improve patient knowledge, skill and motivation. Job aids Data system on improvement in knowledge, skill and motivation 3 self-selected facilities to initially focus on identifying changes that improve self management LS 2 to share changes that have led to improvement after action period of 1 month
Thank You! DISCUSSION 45