1 » Introduction

One of the greatest challenges faced by health care renewal initiatives is improving the quality and efficiency of care delivered to people who suffer from chronic conditions. The impact is broad and the stakes are high. Chronic conditions affect one in three adult British Columbians, and some estimates indicate that up to two thirds of our health care costs are spent treating chronic conditions.

CHSPR's 17th annual health policy conference—As Good as It Gets? Strategies for Improving Chronic Care Management—brought together researchers, clinicians and high-level public servants from B.C. and the United States to discuss the challenges and opportunities surrounding chronic disease management. While British Columbia is ahead of the rest of Canada in this area, we're still at the beginning of a long journey.

There was a general consensus among conference participants that there is an emerging global epidemic of chronic illness, and that the current system, which is focused on acute conditions, is not dealing with it effectively. The importance of co-morbidity—multiple chronic conditions—in the management of chronic illness care and in health planning was also recognized. The 'chronic care model' was a key point of reference in most discussions. Several chronic disease management initiatives were described, both from B.C. and from other jurisdictions, along with various methods of measuring chronic illness care. And there was both optimism and apprehension about how we are doing in our efforts to improve the way we care for people with chronic conditions.

Key Messages

  • The road ahead isn't easy. We're facing a global epidemic of chronic illness, a simultaneous crisis in primary care, and a system designed to treat acute conditions.
  • Most new initiatives in chronic care reform take a systemic view - there is a movement away from blaming individuals (practitioners, patients) to blaming the system.
  • We won't get better outcomes in chronic conditions simply by making isolated adjustments to the existing system. Comprehensive change is needed at all levels of the system.
  • Key requirements of effective chronic disease management include a focus on the chronic care model, patient needs and wants, patient self-management, and the use of non-physicians in the provision of care.
  • We must involve physicians in bringing about change, not simply impose changes on them.
  • New approaches to chronic care reform include bolstered information resources, single-disease-based collaboratives, and nurse-facilitated guided care.
  • Long-term success in any reform initiative involves having access to evidence-based, meaningful and timely data, and looking at the broader economic and political environment.

2 » Setting the Context

Chronic conditions (long-term illnesses expected to persist for more than a year) range from allergies and skin disorders to recurrent depression and cerebrovascular disease. Diabetes and congestive heart failure are two of the highest-profile chronic conditions — others include hypertension, renal failure, and chronic obstructive pulmonary disease.

Chronic conditions affect a significant proportion of the population. A CHSPR study released at the conference found that in 2000/01, more than one third of adults in British Columbia had some form of chronic condition.

Co-morbidity—having more than one chronic condition—is also common. The CHSPR study found that in British Columbia, 30% of adults with a confirmed chronic condition had high or very high co-morbidity, while more than two thirds of seniors had one or more chronic condition. The greater the rate of co-morbidity, the higher the use of health care resources.

The Public Health Agency of Canada estimates that up to 67% of direct health care costs are spent on chronic conditions. Similarly, in the United States, it is estimated that 15% of the older population with co-morbidity accounts for 80% of Medicare program spending.

However, while we're spending large amounts of resources on chronic illness care, the evidence shows that the way we care for people with chronic conditions is often less than optimal, focusing more on treatment of flare-ups than on regular monitoring and prevention.

Five contemporaneous developments

Keynote speaker Ed Wagner, developer of the chronic care model, placed the challenge of managing chronic illness in the context of five contemporaneous developments:

  1. We're experiencing a global epidemic of chronic illness, largely as a result of general increases in life expectancy.
  2. There is increasing concern about the ability of primary care providers to deal with the chronic illness epidemic within the existing system, and coupled with declines in trainees choosing primary care careers and earlier retirement of existing providers.
  3. Although the treatments for chronic illnesses are becoming more effective, accessibility—our ability to get them to the people who need them—is a major problem.
  4. There is a movement away from blaming patients and professionals to blaming the system. We're recognizing that no matter how hard we work to improve outcomes, they won't improve unless we change the system.

The impact of chronic co-morbidity: Understanding chronic conditions and co-morbidity in British Columbia

Building on earlier work with the Vancouver Coastal Health Authority, CHSPR researchers led by Anne-Marie Broemeling profiled patterns of chronic conditions among British Columbia residents, with a particular focus on understanding the impact of co-morbidity.

The study showed that:

  • In 2000/01, 36% of adults and 68% of seniors in B.C. had one or more chronic conditions
  • Chronic conditions were more prevalent in lower-income neighbourhoods and among women
  • 30% of adults with a confirmed chronic condition had high to very high co-morbidity (i.e., multiple chronic conditions)
  • Certain chronic conditions tend to cluster (e.g., 31% of people with diabetes also had hypertension, and 11% had depression)
  • Different conditions carried differing rates of co-morbidity (e.g., 25% of adults with diabetes had high co-morbidity and 7% had very high co-morbidity, while 43% of people with congestive heart failure had high co-morbidity and 21% had very high co-morbidity)
  • Individuals with chronic conditions used more health care services than average adults, after adjusting for age and sex
  • The greater the co-morbidity, the higher the utilization of health care resources
  • Individuals with high-impact conditions (measured by expected short-term resource use and outcomes) and/or high-prevalence conditions (measured using treatment prevalence rates) who were in the no or low co-morbidity category were actually lower users of health care services than average; however, those with very high co-morbidity used many times more services than the population average.

The 30% of adult British Columbians suffering from high or very high rates of co-morbidity have very distinct needs, including coordinated care across a spectrum of conditions.

The implications?

  • Health care providers focusing on single conditions may well miss the opportunity to target an individual's constellation of problems with the right combination of interventions.
  • Studying the presence of a single chronic condition can't accurately help health care planners predict resource needs—it's the combination of conditions that drives the use of services.

3 » What's Wrong with This Picture?

Despite the epidemic of chronic illness, we still have a system oriented to acute illness. In other words, Chad Boult said: "We have a population with chronic conditions being treated in an acute care system."

The current system largely depends on patients initiating contact only when they have an acute problem. The emphasis is on making the appropriate diagnosis based on symptoms and lab results and giving the patient the appropriate therapy. The result? Health care professionals aren't trained to care for people with chronic conditions. There isn't a good flow of clinical information. Regulation and funding are fragmented. Health care providers receive little or no reimbursement for education, empowerment or coordination of care. And little attention is paid to what the patient wants.

Howard Platt provided an example of how the system in B.C. isn't working for people with chronic conditions, specifically diabetes. Canadian guidelines—based on evidence—recommend that people with diabetes have a hemoglobin A1c test every three months. However, in 2002/03, the majority of British Columbians with diabetes got their levels tested less than twice a year. In the 20 to 29 year-old age group, only 20% were having the hemoglobin A1c test regularly.

The potential consequences of this gap in care are significant, because we know that when people with diabetes don't get adequate care early on, significant complications arise later. And in fact, people with diabetes are over-represented in treatment for other conditions. In 2002/03, five percent of British Columbians suffered from diabetes. But 59% of British Columbians who underwent surgery for retinal disorders had diabetes, as did 56% of those who had toes, feet or lower limbs amputated; as did 46% who had dialysis; 32% who had coronary artery bypass surgery; 25% who had coronary angioplasties; and 21% who had cataract surgery.

The current system also tends to send people with particular disorders away from their family doctors to specialists, often driven by literature saying that specialty clinics and centres of excellence get better results than regular family practice. But Dr. Platt argued that taking chronic disease management out of community-based continuing care also has a lot of negative consequences. "It fragments the care, and it sends powerful messages to the family doctors. Like, 'You guys can't cut it.' And they feel demoralized, dispirited, disheartened." This is one of the roots of the crisis in primary care.

Mrs. Carson in regular care

Mrs. Carson is 79-year-old widow suffering from five chronic conditions: congestive heart failure, diabetes, hypertension, coronary artery disease and osteoarthritis. She sees three physicians regularly and has made 19 outpatient visits to those physicians in the last year. She takes eight prescription medications every day, which means filling 22 prescriptions over the course of a year. This year she has had three hospital admissions, spent a total of six weeks in sub-acute care in two different nursing homes, and had a total of five months of home care from two different home care agencies. Altogether this year she has seen eight physicians, six social workers, five physical therapists, four occupational therapists, and 37 registered nurses, and she has been referred to six community agencies.

Mrs. Carson is confused by all this. She takes about half the recommended doses of her medications, and doesn't really follow her diet or monitor her blood as she's been instructed to. She hasn't got around to accessing any preventive services, and although she has heard about advanced directives, no one has had time to go over that with her. Medicare has paid various providers almost $40,000 (not including prescriptions) and Mrs. Carson has covered about $5,000 in expenses above that.

Mrs. Carson rates her quality of life as poor. Her daughter, who lives 10 miles away, has had to reduce her work to half time, and is considering putting her mother in a nursing home.

This care is misdirected, fragmented, inefficient, frustrating and expensive. But Mrs. Carson isn't alone. In the United States, there are about 60 million in her age group, with another 10 million expected by 2010.

— Chad Boult

4 » Changing the System

[The provider team] is not getting results because the system doesn't support them; in fact, that system gets in their way. The system is toxic to getting good results with chronic disease. They try and they run into obstacles. From a government point of view, our job is to remove those obstacles. There are many of them, and we're working at it hard.
— Howard Platt

The current care system isn't designed to provide effective chronic care management. As Ed Wagner put it: "No matter how hard you work, no matter how many hours you put in, no matter how many continuing education courses you go to, if your system remains the same, outcomes and measures of quality are not going to improve."

So what needs to be done?

In order to change outcomes in major chronic illnesses, Dr. Wagner argued, we need a system designed to meet the needs of patients. Access to the most effective prevention and treatments. A primary care infrastructure that can administer effective prevention and treatment. Access to more specialized services for additional support when needed. Supportive communities. Making one isolated change won't change the system. Getting there will require a comprehensive, integrated set of changes in primary care, and change at every level.

The system must support what the chronic care model calls the informed, activated patient. Since the vast majority of decisions made by patients in the management of their conditions are made at home, outside of the doctor's office, it's obvious that the quality of their decision-making will influence outcomes. And while it's important that they receive good information so that they have some knowledge of their condition, what is perhaps even more important is that they have the skills and confidence to be able to make good decisions. "Their skill in managing their diabetes, their confidence in being able make decisions about their diabetes has a far greater impact on their ability to achieve disease control than whether they can answer questions correctly in a test," according to Dr. Wagner.

The chronic care model (Edward H. Wagner) synthesizes available evidence of system changes that improve care for chronic illness

Supporting this type of self-management is a collaborative process, in which patients help professionals define the problem, establish goals, identify barriers, collaborate on the development of alternative strategies to overcome those barriers, agree on a plan, and then follow up to find out what's working and what's not.

A complementary approach, developed for the self-management of arthritis by Kate Lorig at Stanford University, involves lay-led patient education in which trained lay-leaders present highly interactive courses to small groups of patients. Participants receive information, learn new skills, develop higher levels of competence to manage their conditions, and give and receive support from others experiencing similar health conditions.

These new approaches to self-management support are in sharp contrast to traditional patient education: a doctor, nurse or nutritionist delivers a lecture to a class of patients, who then take a test and go home.

In the chronic care model, the informed, activated patient interacts with a prepared, proactive practice team. Not only is the team prepared in terms of their expertise and evidence-based practice, but their office routine and system facilitate productive interactions between patient and team by design—not through added effort. And the only way that can happen is through the use of non-physician team members.

Not using non-physician members of practice teams—or not using them appropriately—may be the biggest barrier to improving chronic illness care. "I know of very few interventions that really make a difference in the lives of people with chronic illness that don't heavily involve the non-physician members of the practice team," Dr. Wagner said. "The literature is crystal clear that the way effective and efficient practices get the work of chronic illness care done is by sharing it among all members of the practice team."

One perceived barrier to the use of non-physicians is liability. However, Rick Hudson argued that these concerns are becoming less pertinent: "The chances of a physician being sued for not having done a hemoglobin A1c on a patient are decreasing as people who live with chronic illness understand more and more what good care looks like and care less and less about who gives it to them."

On the other hand, as the treatment of chronic conditions becomes more complex, it's clear that we need new ways to bring specialized expertise into primary care efficiently and cost-effectively. Obviously, the traditional process of consultation and referral isn't working. People are now experimenting with different ways of linking specialists to primary care that will increase primary care providers' access to expertise without making it inefficient and expensive.

Another prerequisite for major improvement in chronic illness care is structured, planned visits. Traditional reactive, patient-initiated visits for acute situations will continue to constrain the efforts of even the most committed and sophisticated providers.

But systemic change can't be imposed externally. "If there's one thing we've learned in Canada in the past three or four decades, it's that unless the doctors agree and participate, you don't get change," argued Howard Platt. "We have to involve them and make the changes that will make it easier for them to give their patients the care they need."

Finally, Heather Manson suggested that what is needed to bring about all this systemic change in British Columbia is a clearly articulated provincial plan and the sustained funding to implement the plan.

5 » Making It Happen: Approaches, Initiatives, Models

There's a huge gap between what we know and what we do. The what we know piece is the easy bit. The implementation part is the hard bit, and that's what we've been putting our effort into for the last few years.
— Howard Platt

Conference participants outlined a series of new approaches, initiatives and models—both national and international—designed to improve the management of chronic conditions.

Provincial initiatives

Howard Platt described a number of informational initiatives underway across the province: the BC HealthGuide, the BC HealthGuide Online, BC NurseLine (a toll-free 24-hour health information line), patient guides attached to evidence-based care guidelines for physicians, and hundreds of community-based lay leaders to provide education and support for people with arthritis.

Work is also underway to provide patients with more access to their records through the Chronic Disease Management (CDM) Toolkit, which holds key management data from the doctor's record on a secure server. This allows the doctor to share data with other members of the provider team, and gives patients access to the record in the form of a flow chart they can share with pharmacists, nurses or other team members.

At the provider team level, a number of single disease collaboratives are being tested across the province—in diabetes, congestive heart failure, and depression—with the aim of providing doctors with information and other support. Fifty percent of family doctors are now involved in the Northern Health Authority's chronic disease management initiative, with a goal of having over 90% electronically connected by the end of the year.

Support organizations have a key role to play. The College of Family Physicians is working to help doctors coach patients in self-management and decision-making, and the College of Physicians and Surgeons is helping doctors across BC assess their own practice's competency in chronic care management. The province has also introduced financial incentives—including a $75 payment for following clinical practice guidelines—in an effort to broadly implement the guidelines.

John Millar described some preliminary work being conducted in addressing multiple co-morbidities. For example, six pilot sites are being established around the province to look at ways of managing multiple co-morbidities, including patient self-management and improved health care system navigation. Another possible approach involves conducting disease prevention at every stage of the chronic condition evolution. For example, someone with the cluster of diabetes, congestive heart failure and depression can benefit from simple care such home-based fall-prevention support or flu shots, to more comprehensive care such as income, housing and social support.

In addition, all of the health authorities in the province have agreed to invest in SharePoint, a communications technology that connects users to information, applications and collaborative tools. The technology provides the primary care team, specialists, patients and families with access to clinical practice guidelines, protocols, integrated care pathways, individualized care plans, community resource maps, self-management tools, and scheduling. It will also allow sharing of clinical information. Four of the six co-morbidity pilot sites mentioned above will use SharePoint.

Collaboratives

Chris Rauscher defined a collaborative as "a systematic way of learning and making changes." He emphasized systematic because of the tendency in health care to lurch from one idea to another, trying to bring about change in a way that isn't always methodical. Dr. Rauscher called the collaborative "the first methodology I've seen that has allowed groups of diverse people to come together to support…people with chronic diseases and that is actually going to make a difference. You're able to achieve amazing results if you do it in a systematic way."

The congestive heart failure collaborative was the first effort of its kind in Canada. Primary care physicians, cardiologists, regional health authorities, the Ministry of Health Services, the Health Heart Society of B.C. and numerous other heart health partner organizations worked together for 15 months in 2003/04 in an effort to implement chronic illness population management for patients with congestive heart failure. The goal was to build an infrastructure for chronic disease management based on the chronic care model that would maximize the length and quality of life for patients with chronic disease, while maintaining or decreasing the costs. The collaborative was highly successful in all of its measures, showing that systematically making a few small changes at a time and then assessing what works can achieve results.

The B.C. Diabetes Collaborative, currently underway, is designed to give family physicians appropriate support and opportunities to make practical, small-scale improvements in their clinical practice. The collaborative developed targets for good diabetes management based on the B.C. Diabetes Care Guidelines. The key: Patients setting their own self-management goals with support from their family physicians.

The Northern Health Authority's community collaborative involved seven northern B.C. communities working towards the goal of improving health outcomes for patients through organizational changes in primary health care. The initial focus was on congestive heart failure, diabetes, co-morbid depression, hypertension and kidney disease. The approach used interdisciplinary, community-based teams to integrated care.

The Vancouver Coastal Health Authority has three collaborative initiatives underway. In Richmond, a wellness centre is bringing together physicians who are interested in working differently, and extensive community partnerships are emerging. The North Shore is using a handheld personal digital assistant—containing guidelines, the CDM Toolkit, call schedules, and local information—as the centre of their network. And a practice enhancement collaborative is pushing for the embedding of chronic disease management approaches in electronic medical record systems in the province.

Dr. Rauscher outlined a number of key challenges that have emerged over the course of developing these collaboratives, including:

  • You have to work across all of the levels—patient, provider team, organization and environment—to be successful.
  • It's difficult to facilitate systemic change when primary care is in crisis, family physicians are leaving practice, and new graduates are choosing other types of practice.
  • The current system isn't set up to support self-management. Office redesign and the expanded training of receptionists and medical office assistants, are key.
  • The shift to prepared proactive teams—for example, getting family physicians working with specialists—is difficult, partly because they're not paid to work together.
  • Knowledge dissemination is an obvious challenge. One approach is to support local champions—providers, lay leaders and others—who can talk to people in their communities and recruit them for various initiatives.
  • There are also some obvious practical issues, such as how to do all this in a ten-minute visit.

The Vancouver Coastal Health Authority

Heather Manson described Vancouver Coastal's philosophy in terms of chronic disease management: "We're committed to supporting healthy lives in healthy communities with our partners through care, education and research." The notion of healthy lives embraces not only preventing disease, but also helping people live well with chronic disease or disability, and healthy communities speaks to partnerships with and in the community.

A key component of achieving this vision is the renewal of primary health care, which is the point of access, and the place where people spend the largest part of their time. Chronic disease management, in turn, is seen as resting within primary health care.

One approach being used by the health authority involves family practice networks—links with and among family physicians either electronically or through a shared care model. Primary health care will in turn be connected to public health and prevention, through linkages between these family practice networks and components of the public health system, such as public health nurses and home care nurses.

The work is incremental, however—doctor by doctor, group by group, step by step—which limits how quickly the transformation can be made. The paradigm shift that will bring about that transformation may not happen within the current term funding. "It's really challenging to demonstrate in the short term that you've made a difference while knowing … that the work is incremental," Dr. Manson said.

A further challenge is the fact that chronic disease management in B.C. is currently a provincial-level initiative, rather than a specific program under the ownership or sponsorship of any one health authority. In order to be truly effective, Dr. Manson argued, chronic disease management needs to be integrated with health authority programs.

Guided care

Chad Boult described guided care, a model being used in Baltimore. The initiative began with a search in the literature for evidence-based innovations in chronic disease management. The innovations that emerged from that search—geriatric evaluation and management, transitional care, self-management, the health enhancement program, and caregiver training and support— were then packaged in a single delivery system called guided care.

In this amalgam of evidence-based approaches, a specially trained nurse located in a primary care practice works with two or three primary care physicians to care for high-risk patients with the help of a specially designed computer system.

The nurse does a comprehensive geriatric assessment in the patient's home to determine needs and preferences. Back at the office, the nurse gathers more information from the patient's medical records and enters it into the guided care system on a laptop computer. The system also contains the latest evidence-based guidelines for the top 12 chronic conditions, so it can incorporate best-practice recommendations into a care plan with a single key stroke. The nurse then discusses all aspects of the plan with the primary care physician.

The care plan is a succinct, two-page document that identifies the patient's condition(s) and the recommendations for medication, specialist referrals, diet and activity, and self-monitoring. For each problem, the care plan provides a space where the nurse and patient can write in an agreed-upon goal, or specify symptoms the patient should watch for.

The nurse's job is then to make sure that every health care provider who comes in contact with the patient has the care plan in their hands. The idea is that people will tend to follow something that is comprehensive, well organized and succinct.

The system also contains a database of available community services, so if the patient needs a meal program or a referral to the alzheimer's Association, the nurse can quickly pass on that information. The system also provides automatic reminders based on a patient's plan—if the patient is supposed to check her blood sugar every day and then call the nurse at the end of the week, the computer will remind the nurse if the patient hasn't already called.

The nurse supports lay-led self-management classes (by referring patients and supporting the lay leader) and provides caregiver support, through monthly support groups, structured in-person online education, and 24-hour telephone availability for caregivers.

A one-year feasibility pilot test of guided care in Baltimore—with one nurse, one primary care practice and 50 high-risk patients—was completed in 2004. The results of a primary care assessment survey at the end of the pilot showed that patients gave guided care a higher quality rating than normal care in five out of five domains. Cost comparisons showed that people in guided care had fewer hospital stays and emergency department visits, but more visits to primary care providers and specialists, with slightly lower overall costs. The physicians involved in the study felt that guided care significantly improved their ability to provide quality care.

A five-year randomized trial of guided care has now begun, involving 22 primary care physicians, 340 caregivers and 850 patients across seven sites. Participants will be assigned to guided care or regular care, and outcomes will be measured, including satisfaction, health function, and costs. A stakeholder advisory committee, consisting of individuals from every stakeholder group, will be consulted throughout the study.

Mrs. Carson in guided care

Guided care for Mrs. Carson begins with a two-hour interview at home. She then attends a seven-session self-management course, and she and her daughter both receive educational material. The guided care nurse helps Mrs. Carson to integrate all of her care, provides frequent telephone reminders, and helps Mrs. Carson link with health care providers and community agencies. Mrs. Carson's daughter has access to caregiver education and support.

The result is that Mrs. Carson has fewer emergency department visits and hospital admissions, although she visits her primary care physician and specialists slightly more often than before. There is a small savings in the annual cost of her health care. Mrs. Carson rates her quality of care as improved.

For Mrs. Carson's physician, guided care provides assistance with his most challenging patients, in the form of comprehensive care plans, proactive follow-up, response to family's phone calls, communication with other health care providers as the patient moves among them, and facilitating transitions out of the hospital.

— Chad Boult

6 » Measuring Chronic Illness Care

You have to measure, measure, measure, but you need a balance between disease-specific measures focusing on process and outcomes, and generic indicators from the patients' perspective that can reflect their overall care.
— Robert Reid

Robert Reid capped off the conference by describing four reasons for measuring chronic illness care: to identify gaps in care; to provide feedback for quality improvement cycles; developing health plan scorecards and provider profiling; and to support pay-for-performance initiatives.

Dr. Reid provided two examples of pay-for-performance initiatives in other jurisdictions.

The UK's National Health Service has allocated one billion dollars in new funding to a points-based system focusing on targets in clinical care, practice organization and patient experience. Family physicians are able to earn up to 1,000 points at 40 pounds per point—potentially about 20% of a physician's income. Clinical care points are based on both process and intermediate outcome measures for 10 chronic conditions—for example, whether total cholesterol is measured and whether the results are within acceptable limits.

In California, about $50 million in new spending is being used to provide incentives for 215 medical groups and about 45,000 physicians. Half of the fund is paid out for quality of care indicators, 40% for patient experience indicators, and 10% is being invested in information technology.

Regardless of the jurisdiction, measurements of chronic illness care must be evidence-based, valid, reliable and sensitive to changes in care, meaningful and timely for key stakeholders, and resistant to manipulation (especially in a pay-for-performance context). Measures should also provide a comprehensive picture of quality, use data that can be economically collected, and be within the control of the clinical team when used for provider performance. Typically two sources of data are used to evaluate care: administrative data or medical charts, and patient and provider surveys. Many organizations in the U.S. are now using a combination of the two to develop performance indicators.

Disease-specific measures from administrative data are increasing in both number and precision. However, it's important to ask questions such as: What is the right mix of outcome- and process-based measures, and of intermediate and long-term outcome measures? How can measures be combined to assess overall quality of care for a particular disease? Do administrative data systems support many of these measures?

Is it possible to measure chronic care in terms of the chronic care model? Can the informed, activated parent be measured? Can prepared, proactive teams be measured?

One new instrument, the Patient Activation Measure, attempts to do this through a self-administered, 22-item questionnaire that measures patients' engagement in their care. Another approach, the Assessment of Chronic Illness Care, is a questionnaire for providers to help them evaluate their chronic care, focusing specifically on how that care is organized. Finally, the Patient Assessment of Chronic Illness Care, which complements the Assessment of Chronic Illness Care, is a self-administered 20-item patient questionnaire that provides generic, patient-centred assessment and helps focus improvement by identifying gaps in care that are not readily apparent to providers. The five domains in this model closely (but not perfectly) the domains of the chronic care model: patient activation, delivery system design, goal setting, problem solving and contextual counselling, and follow-up and coordination. The Patient Assessment of Chronic Illness Care has actually been shown to perform very well, with good validity in most domains.

7 » Grounds for Optimism or Despair?

An enormous amount of progress is being made, specifically here in B.C…so I'd like to start with that and then say, given that sense of energy and enthusiasm, are you really sure you wanted to haven an economist close the conference? [laughter] I'm here to restore a sense of balance.
— Robert Evans

Many speakers at the conference noted the passion and excitement in the room, particularly as new models and approaches were presented. Many also expressed their belief that there are tremendous grounds for optimism about the future of chronic disease management, and that real progress is being made, especially in B.C.

However, health economist Robert Evans sounded a cautionary note. If, as noted by many speakers, the system is perfectly designed to achieve the results that it achieves, revolutionalizing the system isn't going to be easy. "It's not going to be simple to embed in it more effective ways of doing things if the system itself is not only inimical to that, but is in fact designed not to achieve those results," Dr. Evans said.

None of the speakers suggested that the changes and initiatives being described would result in significant cost savings. Indeed, Rick Hudson warned that better primary care is going to cost more, "And if it doesn't cost more, it's probably not a whole lot better." He emphasized the need to address strategic investment priorities. However, Dr. Evans cautioned that there is still the question of where the financial resources are going to come from.

Although some initiatives are underway, there has been little progress on the training and use of intermediate-level health personnel, an essential component of improvement in the quality of care for chronic illness. Other issues, like the epidemic of obesity, and its implications for chronic illness and primary care, have yet to be addressed.

Finally, Dr. Evans reminded attendees that it's vital to invoke broader macro-economic or macro-political contexts. For example, the primary thrust of the American administration's current policy is two-fold: controlling health care costs by increasingly pushing them on to the end user, and protecting drug companies against lawsuits. These measures can only work to limit access to the kinds of improvements and initiatives described at the conference. And while most countries don't operate in this kind of environment, these broader policies do form part of the global political framework and must be considered as we move forward.

» Speakers

Kelly Barnard
Senior Medical Consultant, Knowledge Management and Technology Division, BC Ministry of Health Services

Dr Kelly Barnard spent the first ten years of her career in northern BC as a family practitioner with special interests in geriatrics and psychiatry. A participant in many community activities, she served as the medical director of the Diabetes Education Centre and as an evaluator for the provincial program. She completed her Masters of Health Science at the University of British Columbia in 1995 and returned to the Northeast to serve as medical health officer and CEO of the regional Community Health Services Society. Between 1998 and 2002, she worked as a medical consultant with the BC Ministry of Health in a variety of areas, including primary health care, rural health, physician compensation, planning and policy. At present, she is seconded from her position as a medical health officer at the Vancouver Island Health Authority to provide medical consultation in the Knowledge Integration and Development Branch of the BC Ministry of Health Services.

Charlyn Black
Director, Centre for Health Services and Policy Research

Charlyn Black, MD, ScD, Director and Faculty, is a nationally recognized health policy researcher, and a professor in the Department of Health Care and Epidemiology at UBC. Dr Black oversees CHSPR's research and data development activities, and her research focuses on the creation of population-based information systems, the use of administrative data to monitor the quality and effectiveness of medical care, and the development of data-driven tools to inform and improve health care delivery. She serves on the board of directors of Saskatchewan's Health Quality Council, and provided input into a recent US report outlining a framework for restructuring the American system of health statistics. Prior to her appointment at UBC, Dr Black was a founding member of the Manitoba Centre for Health Policy at the University of Manitoba. Over a 12-year period - as a senior researcher and then co-director of the centre - she played a key role at the interface between research and policy and in ensuring the relevance of the centre's work. Between September 2000 and August 2001, Dr Black was a senior advisor to the president of the newly created Canadian Institutes of Health Research (CIHR) and a visiting scientist and senior advisor to the president and CEO of the Canadian Institute for Health Information (CIHI). She has also served on a number of influential committees, including the Federal/Provincial/Territorial Advisory Committee on Health Services, the Canadian Population Health Initiative Council, the Health Reports Experts Group of CIHI, and the Steering Committee of the Western Canadian Waiting List Study. Dr Black obtained her MD from the University of Manitoba and her PhD in health services research from the Johns Hopkins University in Maryland.

Chad Boult
Director, Lipitz Center for Integrated Health Care
Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health

A geriatrician by training, Chad Boult, MD, MPH, MBA, has extensive experience in developing, implementing and evaluating the outcomes of new systems of health care for older populations. His current research includes guided care, a new model of primary care for older people with multiple chronic conditions. Now a professor at Johns Hopkins University, he directs the Lipitz Center for Integrated Health Care in the School of Public Health, and leads the health services research program of the Division of Geriatric Medicine and Gerontology in the Department of Medicine. In the past, Dr Boult has published projections of the number of disabled older Americans (and Britons) in the 21st century, and has provided consultation to dozens of health care organizations. He created the first validated questionnaires for identifying high-risk people who would benefit from special care (the Pra, the PraPlus, the Pie, and the Pme). He co-edited a book entitled New Ways to Care for Older People: Building Systems Based on Evidence, and he now edits the “Models and Systems of Geriatric Care” section of the Journal of the American Geriatrics Society.

Anne-Marie Broemeling
Director, Research and Evaluation, Strategic Information and Planning, Interior Health Authority
Faculty, Centre for Health Services and Policy Research

Anne-Marie Broemeling is director of research and evaluation for the Interior Health Authority, and faculty at the Centre for Health Services and Policy Research. Her research focuses on chronic disease co-morbidity for residents of BC and the impact of co-morbidity on utilization of services. She is the lead author of the recent CHSPR report, Chronic conditions and co-morbidity among residents of British Columbia. Anne-Marie is also involved in primary health care research at CHSPR, including use of administrative and other existing data sources to develop measures for the primary health care logic model. Her doctoral research focused on the utilization of home care services in conjunction with acute care stays in BC to determine whether home care was used as a substitute or complement to acute care days. Anne-Marie holds a BA in economics from the University of Victoria, an MSc in International Relations from the London School of Economics, and a PhD in Health Services Management and Policy Sciences (specializing in health economics) from the University of Texas School of Public Health.

Robert G. Evans
Senior Faculty, Centre for Health Services and Policy Research
Professor, Department of Economics, University of British Columbia

Robert G. Evans is one of the world’s leading health economists. He is a fellow of the Canadian Institute for Advanced Research and was director of the institute's Population Health Program from 1987 to 1997. From 1985 to 1997 he held a National Health Research Scientist award at UBC, and has received a CIHR Senior Investigator award for the period 2001-05. Major publications include Strained Mercy: The Economics of Canadian Health Care (1984), and Why Are Some People Healthy and Others Not? The Determinants of Health of Populations (1994) [senior editor]. Evans’ studies of health care systems and policies have led to a number of invitations to provide policy advice to the Canadian federal and provincial governments. He has also been a consultant and lecturer on health care issues to a number of governments and other public agencies in the United States, Europe, Asia and the South Pacific. Evans was a member of the British Columbia Royal Commission on Health Care and Costs in 1990-91, and of the National Forum on Health, chaired by the prime minister of Canada, from 1994 to 1997. He is an honorary life member of the Canadian College of Health Services Executives and of the Canadian Health Economics Research Association, a member of the National Academy of Social Insurance (United States), and a fellow of the Royal Society of Canada. He was awarded the 2002 Health Services Research Advancement Award from the Canadian Health Services Research Foundation, and the University of British Columbia’s premier research prize, the Professor Jacob Biely Faculty Research Prize in 2003. In 2004, Evans was appointed an Officer of the Order of Canada, and was recently designated as a Killam Professor at UBC. He received his undergraduate degree in political economy from the University of Toronto and a PhD in economics from Harvard University.

Richard E. Hudson
Physician and Consultant

Rick Hudson, MD, CCFP, is a primary care physician and health policy and program consultant living in Victoria, BC. An Australian by birth, Rick received his MD from the University of Alberta in 1974. Rick has over 15 years experience in primary care practice, both as an emergency room physician and as a family doctor at James Bay Community Health Centre. He joined the BC Ministry of Health in 1990 as a medical consultant in the policy and legislation unit. In that role he provided policy and program advice to senior management in a variety of portfolios, including primary health care, mental health, pharmaceutical policy and medical workforce planning.

Heather Manson
Vice-President, Health Services Integration, Vancouver Coastal Health

Dr Heather Manson is a graduate of the University of British Columbia’s medical school and a fellow of the Royal College of Physicians and Surgeons in internal medicine and haematology. After ten years of private practice in Richmond as an internist/haematologist, she was appointed senior medical director and medical health officer for Richmond while completing a Master of Health Sciences in health care and epidemiology. As Vice-President, Health Services Integration for the past two years, Dr Manson’s chief role is to support Vancouver Coastal Health in achieving its strategic goals of improving health outcomes and creating a sustainable health care system by creating a continuum of care focused around the needs of the patient, client, resident or population. To enable integration across the continuum of care, Vancouver Coastal Health has created three strategic networks (acute, primary health care and community care) and a patient-centred focus spanning the continuum within Dr Manson’s portfolio. Dr Manson has been an active member of Pandemic Influenza Contingency Planning committees at both the federal and provincial levels. Dr Manson is a clinical assistant professor in the Department of Health Care and Epidemiology at UBC. She is married with three children, and a resident of Steveston, BC.

John Millar
Executive Director, Population Health Surveillance and Disease Control Planning, Provincial Health Services Authority

Dr Millar is the executive director of Population Health Surveillance and Disease Control Planning for the Provincial Health Services Authority in BC. Previously he served as vice-president, Research and Population Health, for the Canadian Institute for Health Information in Ottawa; and as the provincial medical health officer in BC. Dr Millar was born in Vancouver and graduated in medicine from the University of British Columbia. He has a background of international health experience, having spent two years with the Zambian Flying Doctor Service and ten years as a medical officer and assistant secretary for health in Papua New Guinea. His interest in third world health problems continues, and in recent years he has worked on projects in Laos, Trinidad, Brazil, Kosovo and Transcaucasia.

Howard Platt
Director, Utilization Branch, BC Ministry of Health Services

Dr Howard Platt is director of utilization management for the British Columbia Medical Services Plan (MSP). MSP insures the province’s four million residents for medically required services and pays about sixty million claims a year, valued at close to $2 billion. For the past nine years, Howard has been reviewing MSP utilization and leading the Clinical Practice Guidelines program. His work on developing registers of the population with specific disorders, standards of care derived from the guidelines, and the means to assess the care provided against the standards using available administrative data, have been the major stimulus leading to BC’s Chronic Disease Management initiative. Dr Platt received his medical degree from the University of Manchester (UK) in 1967. He was previously the provincial medical consultant for Alberta Health, a role he assumed in 1988 after 15 years in family practice in Alberta.

Chris Rauscher
Chair, Province-wide Chronic Disease Collaborative for Patients with Congestive Heart Failure in British Columbia

Dr Chris Rauscher is a physician who sees frail elderly people at home in the community. He has taken that practical experience into his quality improvement work for population health and systems re-design across BC. He was the co-chair of the first chronic disease management collaborative in BC, the Congestive Heart Failure Collaborative. He is the physician lead for chronic disease management with Vancouver Coastal Health.

Robert Reid
Associate Director, Department of Preventive Care, Group Health Cooperative, Seattle WA
Faculty, Centre for Health Services and Policy Research

Robert Reid is a primary care physician and health services researcher whose research interests centre on the interface between primary and specialty care, ambulatory case-mix adjustment, measurement of quality of primary care, and primary care organization and design, as well as the translation of preventive care research into day-to-day clinical practice. He is an assistant professor in the Department of Health Care and Epidemiology, and associate member in the Department of Family Practice, at the University of British Columbia. Robert is currently based at the Group Health Cooperative in Seattle WA, where he is assistant investigator in the Center for Health Studies and associate director in the Department of Preventive Care. He obtained his BMedSci and MD at the University of Alberta. He also completed an MPH in epidemiology, a medical residency in public health and a PhD in health policy and management at the Johns Hopkins School of Public Health. Robert is a fellow of the American College of Preventive Medicine and a scholar of the Michael Smith Foundation for Health Research.

Edward H. Wagner
Director, MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative, Seattle WA

Ed Wagner, MD, MPH, FACP, is a general internist/epidemiologist and director of the MacColl Institute for Healthcare Innovation at the Center for Health Studies (CHS), Group Health Cooperative in Seattle WA. He served as director of the CHS since its inception 15 years ago and resigned in April 1998. He has since turned his energy towards directing the MacColl Institute for Healthcare Innovation within CHS. This institute is concerned with developing and evaluating health care innovations which serve the needs of the chronically ill. He is also professor of health services at the University of Washington School of Public Health and Community Medicine. Current research interests include the development and testing of population-based care models for the frail elderly, and for diabetes, cancer, and other chronic illnesses; the evaluation of the health and cost impacts of chronic disease and cancer interventions; and interventions to prevent disability and reduce depressive symptoms in older adults. Dr Wagner serves on the editorial boards of Health Services Research, the Journal of Clinical Epidemiology, and BMJ-USA, acts as a consultant to multiple federal agencies and private foundations, and is a member of the National Cancer Policy Board. As of June 1998, he has directed Improving Chronic Illness Care (ICIC), a national program of The Robert Wood Johnson Foundation. The overall goal of ICIC is to assist health systems improve the care of chronic illness through quality improvement and evaluation, research and dissemination. He is also principal investigator of the Cancer Research Network, an NCI-funded consortium of eleven health maintenance organizations conducting collaborative cancer effectiveness research.

» Copyright

As good as it gets? Strategies for improving chronic care management
Proceedings of the 17th annual health policy conference of the Centre for Health Services and Policy Research, February 25, 2005, was produced by:

Centre for Health Services and Policy Research
The University of British Columbia
429-2194 Health Sciences Mall
Vancouver, BC Canada V6T 1Z3
Tel: (604) 822-1949
Fax: (604) 822-5690
Email: enquire@chspr.ubc.ca

This conference was supported by a financial contribution from the British Columbia Ministry of Health Services.

Proceedings prepared from conference transcripts by Merrie-Ellen Wilcox, Inkstone Writing and Editing.

This document is protected by copyright. It may be distributed for educational and non-commercial use, provided the Centre for Health Services and Policy Research is credited.