A Model that Benefits the Chronic Patients

Chronic Care Model

Model Elements

The Chronic Care Model (CCM) recognizes the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change theories under each element, in turn, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.

The Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.

Dr Wagner developed the chronic care model and his collaborates helped in the development as well as the refinement of the model. Further information can be found in this link I have provided: http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18

Promoting effective change in provider groups to support evidence-based clinical and quality improvement across a wide variety of health care settings.

From many surveillance data collected over the past years, we can see that many chronic diseases has emerged in the population and Almost half of all people with chronic illness have multiple conditions. As a result, many managed care and integrated delivery systems have taken a great interest in correcting the many deficiencies in current management of diseases such as diabetes, heart disease, depression, asthma and others.

Those deficiencies include:

• 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

To overcome the deficiencies, it will require the transformation of health care, from a system that is essentially reactive, responding mainly when an individual is sick, to one that is proactive and focused on keeping an individual as healthy as possible. Thus, to accelerate the transition, Improving Chronic Illness Care (ICIC) created the Chronic Care Model (CCM), which summarizes the fundamental elements for improving care in health systems at the community, organization, practice and patient levels.

The CCM consists of two main components, which is the health system and the community. Each of the components contains a few of the fundamental elements.

The model suggests that the patient-provider interactions resulting in care that improves outcomes are found in health systems that:

· have well-developed processes and incentives for making changes in the care delivery system

· assure behaviourally sophisticated self-management support that gives priority to increasing patients' confidence and skills so that they can be the ultimate manager of their illness.

· reorganize team function and practice systems (e.g., appointments and follow-up) to meet the needs of chronically ill patients

· develop and implement evidence-based guidelines and support those guidelines through provider education, reminders, and increased interaction between generalists and specialists

· enhance information systems to facilitate the development of disease registries, tracking systems, and reminders and to give feedback on performance.

Health system

Delivery System Design

Assure the delivery of effective, efficient clinical care and self-management support

• Define roles and distribute tasks among team members
• Use planned interactions to support evidence-based care
• Provide clinical case management services for complex patients
• Ensure regular follow-up by the care team
• Give care that patients understand and that fits with their cultural background

Clinical Information Systems

Organize patient and population data to facilitate efficient and effective care

• Provide timely reminders for providers and patients
• Identify relevant subpopulations for proactive care
• Facilitate individual patient care planning
• Share information with patients and providers to coordinate care
• Monitor performance of practice team and care system

Decision Support

Promote clinical care that is consistent with scientific evidence and patient preferences

• Embed evidence-based guidelines into daily clinical practice
• Share evidence-based guidelines and information with patients to encourage their participation
• Use proven provider education methods
• Integrate specialist expertise and primary care

Community

Resources and Policies

Mobilize community resources to meet needs of patients

• Encourage patients to participate in effective community programs
• Form partnerships with community organizations to support and develop interventions that fill gaps in needed services
• Advocate for policies to improve patient care

Self-Management Support

Empower and prepare patients to manage their health and health care

• Emphasize the patient's central role in managing their health
• Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up
• Organize internal and community resources to provide ongoing self-management support to patients

By focusing on the improvement of those 5 elements, the individuals whom are suffering from chronic diseases will be treated, managed, and received the medical attention needed in order for them to live life productively without complications and deterioration of their disease condition.

References:

http://www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.htm

http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

CDM? CCM?

Chronic Disease Management (CDM)

As I was preparing for my Week 4 tutorial, I came across something intriguing that I would like to share it to those who read my blog on health system. The interesting yet intriguing read was about chronic care management.

What is chronic care management? What is chronic disease management?

Let’s begin by understanding the term chronic disease. Firstly, chronic diseases are prolonged conditions that often do not improve and are rarely cured completely. Diabetes, depression, congestive heart failure, hepatitis and asthma are examples of chronic diseases. Approximately 1 in 4 British Columbians have benn diagnosed with one or more chronic diseases.

Chronic illness has a profound effect on the physical, emotional and mental well-being of individuals suffering from it, often making it difficult to carry on with daily routines and relationships. However, in many cases, deterioration in health can be minimized by good care. This often depends upon individual choices made on a daily basis as well as the collaboration of the physicians in charge as well.

Chronic care management encompasses the oversight and education activities conducted by professionals to help patients with chronic diseases such as diabetes, high blood pressure, lupus, multiple sclerosis and sleep apnea learn to understand their condition and live productively with it. This term is equivalent to disease management (health) for chronic conditions, i.e. Chronic Disease Management. The effort involves motivating patients to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.

Chronic disease management (CDM) is a systematic approach to improving health care for people with chronic disease. Health care can be delivered more effectively and efficiently if patients with chronic diseases take an active role in their own care and providers are supported with the necessary resources and expertise to better assist their patients in managing their illness.

So, may I ask why CCM/CDM emerges or surfaces into the medical health system? This is because usual care is not doing the job; dozens of surveys and audits have revealed that sizable proportions of chronically ill patients are not receiving effective therapy, have poor disease control, and are unhappy with their care.

Although acute care has characterized all medical care until recently, several varieties of managed care have emerged in the past decades in an effort to improve care, reduce unnecessary service utilization and control spiraling costs. Despite its initial promise, however, managed care has not achieved truly coordinated care. In actual operation it appears to emphasize its fiscal goals. Moreover, managed care does not address the complexity of chronic conditions, and in the interests of cost-cutting, tends to reduce time with patients rather than increase it.

Well, Dr. Wagner has his own opinion on the matter. He believes that if we are to improve care for most patients with chronic illness, the evidence strongly suggests that we reshape our ambulatory care systems for this purpose. Primary care practice was largely designed to provide:

• ready access and care to patients with acute, varied problems,
• with an emphasis on triage and patient flow;
• short appointments;
• diagnosis and treatment of symptoms and signs;
• reliance on laboratory investigations and prescriptions;
• brief, didactic patient education; and
• patient-initiated follow-up.

Patients and families struggling with chronic illness have different needs, and these needs are unlikely to be met by an acute care organization and culture. They require:

• planned, regular interactions with their caregivers,
• with a focus on function and prevention of exacerbations and complications.

This interaction includes:

• systematic assessments,
• attention to treatment guidelines, and behaviourally sophisticated support for the patient's role as self-manager.
• education to the patient on the benefits of treatment and the risks of not properly following their treatment regimen.
• patients need to be motivated to comply because treatment usually produces an improved state, rather than the results that most patients desire -- a cure.

These interactions must be linked through time by clinically relevant information systems and continuing follow-up initiated by the medical practice.

In the next post, I would like to emphasize on the elaboration of a chronic care model developed by Dr. Wagner and his collaborators, its standards and guidelines, importance, structure as well as its components. Tune in to my next post as it will reveal the solution for tackling the problems that occurred in the current acute-care model of care delivery.

References:

Wagner, E.H. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

Ware, N.C., et al. (2000). Clinician experiences of managed mental health care: A rereading of the threat. Medical Anthropology Quarterly, 14(1), 2-27.

Wagner EH. Managed care and chronic illness: health services research needs. Health Serv Res. 1997;32:702-14.

http://en.wikipedia.org/wiki/Chronic_care_management

http://www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdm.htm

The Role of PHC in Developing Countries

PHC

After having an interesting and interactive discussion during a Week 4 tutorial session with my group mates, I am spurred by my strong motivation and interest to share the content of discussion about PHC in our tutorial seesion.

First of all, What is PHC? What does this medical abbreviation mean?! Ok, I will let you know right here, right now. PHC stands for Primary Health Centre. It is in accordance with the Alma Ata Declaration, 1978 by the member nations of WHO; in which PHCs were established to provide accessible, affordable and available primary health care to people.

The Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care(PHC), Almaty (formerly Alma-Ata), currently in Kazakhstan, 6-12 September 1978.^[1]It expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world. It was the first international declaration underlining the importance of primary health care. The primary health care approach has since then been accepted by member countries of WHO as the key to achieving the goal of "Health for All".

In South Asia, PHCs are the basic structural and functional unit of the public health services in developing countries. They are the cornerstone of rural healthcare where in these rural places, health services and healthcares are scarce. Therefore the establishment of PHCs and their sub-centres in rural areas are to meet the health care needs of rural population.

Objectives of PHC are organizing health efforts that are comprehensive, integrated, equitable, acceptable and affordable by the community, with active participation of the community and use the results of science and appropriate technology, a cost that can be carried by government and society. Health effort was organized by focusing on service to the wider community in order to achieve optimal health degree, without sacrificing quality of service to individuals. Lastly, they should provide preventive, promotive, and curative to rehabilitative either through the efforts of individual health (UKP) or public health efforts (SME).

Each primary health centre covers a population of 1,00,000 and spread over about 100 villages. Other sources, said that theoretically every 30,000 population gets one PHC. Each PHC has five or six sub-centres staffed by health workers for outreach services such as immunization, basic curative care services and maternal and child health services. PHCs generally consist of one or more doctors, a pharmacist, staff nurse and other paramedical support staff.

Below are the job scopes of a PHC:

• Medical care.
• Mother and child health care including family planning.
• Safe water supply and basic sanitation.
• Prevention and control of local diseases.
• Collecting statistical information.
• Health education.
• Training of health guides, health workers, dayees.
• Basic laboratory investigations.

In Indonesia, Puskesmas (Pusat Kesehatan Masyarakat) is the PHC that is located at the rural areas of the country. Puskesmas provides in-patient and out-patient services that were agreed by the health centres and health authorities concerned. In providing services in the community, puskesmas usually has a subunit of services such as health centres (puskesmas pembantu), mobile health clinic (puskesmas keliling), neighborhood health center (posyandu), rural health post (pos kesehatan desa) and village maternity posts (polindes).

In India, PHC's form a basic part of the health care system. The Medical Officer who provide services through the PHC's must be a MBBS degree holder. In addition to the provision of diagnostic and curative services, the Medical Officer also acts as the primary administrator for the PHC.

The primary field staff, who provide outreach services, are called "ASHA (Accredited Social Health Activist)" or village health nurse, depending upon the Indian state where the PHC is located. The village health nurse provides service at the point care, often in the patient's home. If additional diagnostic testing, or clinical interventions were required, the patient would be transported to the PHC to be evaluated by the Medical Officer.

Now under national rural health mission PHC are rapidly upgraded. Therefore, there are many health services that can be provided by puskesmas or PHC which includes an ECG (electrocardiogram), minor surgery, neonatal resuscitation, implants, nebulizers, maternal ward and some also have X-rays as well as a defibrillator.

Recently, a selective primary health care (PHC) approach referred to collectively under the acronym GOBI-FFF, these are strategies that are being adopted to improve maternal and child health as part of primary care. GOBI-FFF is a model of a PHC. Respectively they include:

• Growth monitoring
• Oral rehydration therapy
• Breast-feeding
• Immunization
• Family Spacing (planning)
• Female Education
• Food Supplementation

This was further reduced to GOBI only (selective PHC) on the priorities set by donors for poor countries.

References:

www.wikipedia.com (keyword: primary health centre, community health centre, Alma Ata Declaration, Puskesmas)

india.gov.in (keyword: primary health centre)

A Supermarket of Disaster

Merapi, one of the greatest and most active stratovolcano located on the border between Central Jawa and Yogyakarta, Indonesia; is now globally known for its ability to place fears and terror in the 21^st century by unleashing her hot molten lava and spewed ashes across the region of Yogyakarta.

Merapi is the youngest in a group of volcanoes in southern Java. It is situated at a subduction zone, where the Indo-Australian Plate is sliding beneath the Eurasian Plate. It is one of at least 129 active volcanoes in Indonesia, part of the Pacific Ring of Fire – a section of fault lines stretching from the Western Hemisphere through Japan and South East Asia.

Cutaway diagram of subduction zone and an associated stratovolcano.

Stratigraphic analysis reveals that eruptions in the Merapi area began about 400,000 years ago, and from then until about 10,000 years ago, eruptions were typically effusive, and the out flowing lava emitted was basaltic. Since then, eruptions have become more explosive, with viscous andesitic lavas often generating lava domes. Dome collapse has often generated pyroclastic flows, and larger explosions, which have resulted in eruption columns, have also generated pyroclastic flows through column collapse.

Typically, small eruptions occur every two to three years, and larger ones every 10–15 years or so. Notable eruptions, often causing many deaths, have occurred in 1006, 1786, 1822, 1872, and 1930—when thirteen villages were destroyed and 1400 people killed by pyroclastic flows.

A very large eruption in 1006 is claimed to have covered all of central Java with ash. The volcanic devastation is claimed to have led to the collapse of the Hindu Kingdom of Mataram; however, there is insufficient evidence from that era for this to be substantiated.

The 2006 Merapi eruption which was quickly accompanied by a 6.3 Richter Scale earthquake roughly 50 km (30 miles) southwest of Merapi, devastated Yogyakarta and its residence. The districts most affected were Bantul and Gunung Kidul. Even the Immigration Office and the Adisutjipto airport were also affected by the destructive forces of the quake. The earthquake killed 5,000 people and leaving 200,000 people homeless. Many lost their love ones and also their home for shelter. Although this catastrophic event had come to past for almost 4 years, the people Yogyakarta will never forget what struck them on May 27, 2006.

Recently, on 25 October 2010 Merapi erupted three times, spewing lava down its southern and south-eastern slopes. Following the next day, the eruptive events of 26 October were classified as an explosive event with volcanic bursts of ejected material, visible flame and pyroclastic hot air flows. A column of smoke rose from the top to a vertical distance of 1.5 kilometres (0.93 mi) from the summit of the Mount Merapi.

The eruption at 05:55 on the morning of 4 November was reported as being five times stronger than the initial eruption on 26 October 2010. On 4 November Merapi had been erupting for 24 hours without stopping. Heat clouds of 600 to 800 degrees Celsius spread as far as 11.5 kilometres from the crater reaching toward the edge of the then 15 kilometres (9.3 mi) exclusion zone, and lava flowed into the mountain’s rivers.

Merapi erupted early on Friday 5 November 2010. Volcanic ash fell at Cangkringan village and its surroundings 10 kilometres (6.2 mi). Due to continuous large eruptions, the government extended the safety zone to 20 kilometres (12 mi) radius and Yogyakarta's airport was closed again for 3 hours in the morning. Volcanologists reported the eruptions of Friday 5 November to be the biggest since the 1870s and officials announced by loudspeaker that the mountain's danger zone had been expanded to 20 kilometres from the crater. Bronggang, a village 15 kilometres from the crater, had streets blanketed by ash up to 30-centimeters deep. By 5 November more than 100,000 people had been evacuated and the scientists monitoring the events were withdrawn from their posts to a safer distance.

This is just one volcano eruption in Central Jawa and prior to this volcanic activity, 21 other active volcanoes in the Jawa island also show signs of increasing activity recently. The ones that I read about is in Maluku, Sulawesi, Krakatoa island and Bromoh in Surabaya. Not forgetting the Mentawai earthquake plus tsunami that already destroyed hundreds of homes, schools, churches and mosques leaving many homeless and casualties. Therefore, my tutorial doctor once told me about Indonesia being the supermarket for disasters which I could not agree more and actually I would like to change it into A Hypermarket of Disasters.

Not only Indonesia is suffering from the wrath of disasters but other places around the world as well. Iceland just had its eruption of Eyjafjallajokul volcano in April this year and New Zealand also just had its earthquake on September 4.

Lastly, I would like to say that our earth is on its way to its tipping point and if humanity don’t find or reach their tipping point to change soon, we might be able to see the events and images from the 2012 movie.

References:

www.thestar.com.my ( Indonesia volcano shoots new blasts; 21 more rumble)

www.thestar.com.my ( Indonesia volcano forces flight cancellations)

www.wikipedia.com ( Mount Merapi, Stratovolcano)

www.detiknews.com (Merapi Masih Erupsi, Penutupan Bandara Adisutjipto Diperpanjang Hingga 20 November)

http://www.bbc.co.uk/ (New Zealand earthquake damaged 100,000 homes)

http://www.telegraph.co.uk/expat/ (Experiencing the New Zealand earthquake)

What is System Thinking?

System Thinking

What is a system? I am sure there were many who asked this question during Professor Laksono’s lecture.

A system is a set of interacting or interdependent system components an integrated whole, or “whole compounded of several parts of members, system”, literary “composition”.

The concept of an “integrated whole” can also be state as a system embodying a set of relationships which are differentiated from relationships of the set to other elements, and from relationships between an element of the set and elements not a part of the relational regime. The scientific research field which is engaged in the study of the general properties of systems include systems theory, cybernetics, dynamical systems, thermodynamics and complex systems. They investigate the abstract properties of the matter and organization, searching concepts and principles which are independent of the specific domain, substance, type, or temporal scales of existence.

Most systems share common characteristics, including:

· Systems have structure, defined by components and their composition;

· Systems have behaviour, which involves inputs, processing and outputs of material, energy, information, or data;

· Systems have interconnectivity: the various parts of a system have functional as well as structural relationships between each other.

· Systems have by themselves functions or groups of functions.

In this post, I would like to share some concepts on system. There are 7 concepts about system and each describing different ideas and concepts about the function and view of the system.

Environment and Boundaries

Systems theory views the world as a complex system of interconnected parts. We scope a system by defining its boundary; this means choosing which entities are inside the system and which are outside - part of the environment. We then make simplified representations (models) of the system in order to understand it and to predict or impact its future behaviour. These models may define the structure and/or the behaviour of the system.

Natural and Man-made systems

Natural systems may not have an apparent objective but their outputs can be interpreted as purposes. As for man-made systems, it is made or designed with purposes that are achieved by the delivery of outputs. Their components must be related; they must be designed to work as a coherent entity or else they would be two or more distinct systems

Theoretical Framework

An open system exchanges matter and energy with its surroundings. Most systems are open systems; like a car, coffeemaker, or computer. A closed system exchanges energy, but not matter, with its environment; like Earth or the project Biosphere2 or 3. An isolated system exchanges neither matter nor energy with its environment; a theoretical example of which would be the universe.

Process and Transformation process

A system can also be viewed as a bounded transformation process, that is, a process or collection of processes that transforms inputs into outputs. Inputs are consumed; outputs are produced. The concept of input and output here is very broad. E.g., an output of a passenger ship is the movement of people from departure to destination.

Subsystem

A subsystem is a set of elements, which is a system itself, and a component of a larger system.

System Model

A system comprises multiple views such as planning, requirement, design, implementation, deployment, operational, structure, behaviour, input data, and output data views. A system model is required to describe and represent all these multiple views.

System Architecture

A system architecture, using one single coalescence model for the description of multiple views such as planning, requirement, design, implementation, deployment, operational, structure, behaviour, input data, and output data views, is a kind of system model.

Lastly, I would like to say that systems are everywhere and their application in human lives has played a significant role in the development and evolution of science as well as other areas like engineering and physics, social and cognitive sciences, management research, economics, strategic thinking, information and computer sciences and many other more. Therefore it is very important for us to understand systems and how we can apply its concept and theories into our daily lives or more importantly in the area of sciences and medical field.

References:

1. Wikipedia (keyword:system, systems theory)

2. Block 4.2 lecture notes