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Future roles for European hospitals in chronic care delivery

Cor Spreeuwenberg
1 January, 2008  

In the 21st century most patients do not suffer from acute problems but, ­rather, chronic conditions. This has been referred to as an epidemic of ­chronic diseases. Western, industrialised countries are challenged to adapt their healthcare systems to meet the demands of this epidemic.

Cor Spreeuwenberg
MD PhD
Professor
Department of Social Medicine

Bert Vrijhoef
PhD
Assistant Professor
Department of Healthcare Studies

Lotte Steuten
PhD
Assistant Professor

Maastricht
University
The Netherlands

The rise in the number of chronic conditions derives from modern medicine being able to postpone death but unable to cure a lot of diseases completely. Physicians are better at diagnosing early than curing in timely fashion. Life expectancy has been prolonged, but a large percentage of the elderly have to face suffering from chronic conditions during the last years of their life. The gain in quantity of life has not been followed by a parallel gain in the quality of life.
By the nature of chronic illnesses, patients are dependent on medication and healthcare services as well as having to adapt their behaviour. Not all chronic conditions have the same impact. The majority of people with well-treated asthma and diabetes can function normally, while others, such as those with some chronic neurological diseases, are faced with limited functional capacities.

From hospital to GPs
The healthcare system is dominated by hospitals and their orientation on physicians. Since the 1980s there has been growing interest in community care outside the hospital and in primary care. The position of general practitioners (GPs) has been strengthened in most European countries. An important impetus for change was the introduction of a mandatory education scheme for GPs by the EU. Most countries have taken action to facilitate a shift in the responsibility of chronic care management from hospitals to GPs.
However, in most countries it is not clear which patients are expected to be treated in the hospital and which in the community. The care is fragmented within and between healthcare sectors and lacks continuity and understanding of the different needs of chronic patients. Healthcare professionals are familiar with traditional medical treatments but have less knowledge of approaches and interventions to inform patients and to change behaviour. The healthcare system is failing in its power to change its own delivery system. Physicians protect their position and status and question the need for change. The value of management tools and information technology is underestimated, resulting in a lack of effectiveness. A lot of bureaucratic mechanisms control people and systems, resulting in cynicism and lack of motivation.
The healthcare system within our community is changing rapidly. Because of the importance of healthcare for their citizens and the public implications of the vast healthcare expenditures, governments are very interested in the healthcare system. All European countries have public arrangements to ensure that people have access to healthcare. In most countries the healthcare systems are nationalised; in others they are privatised but under heavily publicly ruled conditions. People are educated better and have easy access to information. Instead of the traditional steady relations they look for networks and structures that meet their specific needs. They ask for highly individualised instead of collective services. Citizens want to be autonomous and refuse being dependent on others. Also, in Europe there is a shift from solidarity towards individual responsibility. Public institutions are challenged to compete instead of to cooperate. Privatisation and public–private cooperation are stimulated. Industries have an interest in buying and governing healthcare institutions. They want to impose industrial and market principles on the healthcare system.
 
Philosophy of chronic care
The aims of chronic care are derived from the specific needs of chronic patients and society. Instead of a disease orientation, chronic care will focus on supporting or restoring functions to promote participation in society.

Justifiable quality  Good chronic care will fit the specific needs of the patients and will therefore be
personalised. The guidelines and standards of good clinical care will be followed, and the care will have an integrated orientation.
Organisationally and logistically effective  To promote good care and to avoid errors, unwanted waiting times and doubling of services, it may be expected that the care is given in an organised and logistically effective way.
According to societal needs  The interests of the society in aspects such as cost-containment and increasing workforce capacity must be recognised and respected. Therefore a balance is required between input of resources and results.
To reach these aims, several approaches have been proposed. Three of these will be explored further: integrated care, the chronic care model and disease management.

Integrated care
In order to improve chronic care, the World Health Organization (WHO) has developed the concept of integrated care.1 The WHO has described it as “the bringing together of inputs, delivery, management and organisation related to diagnosis, treatment, care, rehabilitation and health promotion”. Integrated care is seen as a method “to improve services in relation to access, user satisfaction and efficiency”.
Integrated care links the content of care with the process and structure of care delivery. Integrated care can only flourish if it is connected to development of expertise, infrastructure, quality assurance, and research and development.

The chronic care model
Wagner and colleagues have developed a structural framework for organising healthcare to improve ­outcomes among patients with chronic illness.2 The chronic care model (CCM) describes the conditions for good clinical care.
The model can be summarised by six elements deemed to be essential for providing high-quality care to patients with chronic illnesses: delivery system design, self-management support, decision support, clinical information systems, community resources and healthcare organisation.3 A meta-analysis has demonstrated that interventions that contain one or more elements of the CCM can improve outcomes and processes for several chronic illnesses of interest to managed care organisations.4
The facilities influence the primary process in which a prepared, proactive practice team makes an effort to get productive interaction with patients. By these interactions patients become informed and activated in such a way that the functional and clinical outcomes of care will improve.
An exciting element of CCM is the emphasis of self-management and the establishment of the conditions to enable patient self-management by information, education, training and support. Self-management recognises the situation that professional care is available in a very limited way for patients with chronic conditions. It is often overlooked that an average patient with diabetes mellitus who visits his physician four times a year must care 8,764 hours a year for himself without getting support. It is likely that investments in understanding of the disease and the principles of treatment are more efficient than routine consultations alone.
A prepared and proactive practice team is competent in clinical care, has the attitude to see the patients as persons who are primarily responsible for their condition, is able to communicate with all types of patients and their families and can organise the care delivery efficiently. Such a team has multidisciplinary composition; keeps its competencies up to date; delegates tasks to the professional supposed to have the best skills by training and education, often nurses; streams its patients in groups according to complexity and characteristics; applies modern technology; is ready to support and inform; and is
accessible and transparent.

Disease management
A number of definitions are currently in circulation for disease management. The Disease Management Association of America defines it as “a system of coordinated healthcare interventions and communications for populations in which self-care efforts are significant”.5 Personally we prefer the following description: “the programmatic and systematic approach of specific diseases and health problems by using management instruments that aim at the advancement of quality, efficacy and efficiency”.6 The steering information contains measurable outcome parameters which represent the aims of care. Benchmarking, feedback on different levels and steering are used to improve the results constantly. The feedback that is given is concrete, clear and personal. One uses “carrot and stick” mechanisms. Apart from the focus on improvement of care, disease management has also a strong client orientation.
Disease management is a concept that was developed originally in the USA, often by parties outside the healthcare system itself that expect a return on investment (ROI). It focuses on populations instead of individuals and on the application of management instruments to improve care and reduce costs. The main public healthcare programmes in the USA, Medicaid and Medicare, have involved health plans
working with disease management programmes.
In Europe, the concept of disease management is not widely accepted. In countries that have a national plan, such as the UK and Spain, the governments contract out parts of the healthcare services to third parties. In the UK, responsibilities are decentralised. Some primary healthcare trusts cooperate with American organisations such as Kaiser Permanente. In Spain, the regional government of Catalonia has contracted out disease management programmes for diabetes and heart failure. The countries with private systems under public law are introducing disease management programmes. In Germany, the government plays an active role. The authorities managed to stimulate the foundation of large disease-management programmes focused on transferring care from hospitals to the community and the sharing of services.
In the Netherlands, healthcare providers, including large hospitals and organisations supporting family physicians, started designing disease management programmes. At the moment the government has taken the initiative to facilitate the foundation of groups, preferably of family physicians, to organise
disease management programmes, starting with diabetes.

Common elements in chronic care approaches
A number of lessons can be learned from integrated care, the chronic care model and the disease
management approach:
•  Extend clinical care with prevention and social and psychological support.
•  Focus on support of self-management by using instruments such as information, education and change of lifestyle, coping and behaviour.
•  Substitute, if justifiable: often the care can be offered by well-trained nurses; physicians perform better in the role of consultants.
•  Treat people, if possible, in the community and not in hospital settings.
•  Support the use of evidence-based protocols: 80% of care can be protocolised.
•  Look for alternatives to the usual encounters, such as telephone calls or SMS messages. 
•  Keep in mind that family and other informal caregivers see the patient more often than the formal caregivers.
•  Pay attention to the process of care.
•  Use feedback-mechanisms based on relevant data derived from clinical records, financial information systems and patient information;
•  Combine attention to clinical care with that to organisation, financing, education, evaluation and research.
•  Make use of exchangeable technology for information and communication (like Health Level 7 technology).
•  Be a learning organisation, constantly willing and working to improve the delivery of care.

Modelling chronic care in Maastricht
Our group has its home base in Maastricht, the capital of the province of Limburg (one of the 12 provinces of The Netherlands). Maastricht has for the past 30 years had one hospital with a academic status and a catchment population of 150,000 people. In the Netherlands, primary and secondary care are separated completely; GPs work alone or in small groups in the community and medical specialists work exclusively n hospitals. All citizens are supposed to have their own GP. GPs have lists of their patients.
Since the beginning of the 1980s, medical specialists and GPs have worked intensively to cooperate, starting with a facility that supported GPs in diagnosis and treatment. In 1996 the hospital wanted to reduce the number of chronic patients for budget reasons. At that time, the hospital received a lump sum for all care delivered to all patients. It wanted to extend the number of complex patients and had no longer interest in the care of common chronic problems. On the other hand, the GPs were paid on a capitation basis for their care to the socially insured (“sick fund”) patients, being more than 60% of their practice population. GPs had no financial interest in becoming primarily responsible again for the chronic patients, in those days treated by the medical specialists. However, there was a general agreement that too many patients were treated in the hospital without any medical need.
At that time a very small group of dedicated innovators from general practice and internal medicine had plans to change the way of delivering chronic care. For strategic reasons they wanted to start with substitution of care: horizontally from hospital to community or primary care (practices of the GP) and vertically from physician to (specialised) nurse. By this change they wanted to promote “shared care”.

Conclusion
In Europe, several countries are looking for innovative chronic care approaches, combining integrated care; disease management and the chronic care model; and adapting models to European values for healthcare like access for all and equity. At an European level, decentralisation of responsibilities seems to be more important than the way the healthcare system is paid, either publicly or privately.
In chronic care it is more important to focus on support systems for self-management and behavioural changes than on taking over responsibilities, as usually happens in the classic medical approach. Changes are needed at all levels of management. The caring organisation must function as a learning organisation, constantly active in improving its quality. For implementation of these models it is important to follow a step-by-step approach and to look intelligently for urgency and windows of opportunity. Evaluation by critical research may function as an instrument to convince criticasters and to introduce change.

References
1. World Health
Organisation. Innovative care for chronic
conditions. Geneva: WHO; 2002.
2. Wagner EH,
Austin BT, Korff M von, et al. Improving chronic illness care: translating
evidence into action. Health All (Millwood) 2001:20:64-78.
3. Bodenheimer T,
et al. Improving primary care for patients with chronic illness. JAMA 2002:288:1775-9.
4. Tsai AC,et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Managed Care 2005;11:478-88.
5. Disease Management Association of America. Dictionary of disease management terminology. ­Washington, DC: DMAA; 2004.
6. Spreeuwenberg C.
The characteristics for an ideal disease
management
programme. In:
Schrijvers G, et al. Disease management in the Dutch context. Utrecht: Igitur; 2005. p. 9-25.