Integrated Service Delivery
and the Role of Hospitals in
Chronic Disease Management:
Analytical Perspectives
and the Canberra Case Study
Associate Professor Paul Dugdale
European Forum for Primary Care Conference
Galatasary University, Istanbul September 2013
International Hospital Federation Workshop
Improving the response of hospitals to patients
with multi-morbid chronic conditions
• Background and Policy Context
• An approach to understanding reform:
Organization; Expertise; Financing.
Chronic Disease Management in
Canberra Hospital and Health Services
• Current services
• Efforts to integrate with primary health care
Fishing near Canberra
Improving the response of hospitals to patients
with multi-morbid chronic conditions
• The Increasing Burden of Non Communicable
• Combined with current problems in service
– Lack of integration between primary and referral
based care
– Lack of access to primary care drives over-provision of
hospital and referral based care
• Gives clear potential for health gain.
Burden of Chronic Disease
• Most of the world’s population is living longer and dying at
lower rates.
• Leading causes of death are shifting to non-communicable
• Worldwide, the number of people dying from noncommunicable diseases grew 30% in the 20 years to 2010.
• Preventive health care has resulted in more people with
chronic disease (!)
• People are living to an older age, but partly because of this
they are experiencing more ill health, reflected in disability
• in middle- and high-income countries this is due to diabetes,
musculoskeletal disease, depression, CVD and stroke.
• In poor countries, the burden of disease is shifting too, with
the burden from hypertension, diabetes has markedly
Current problems in health service
• Without universal coverage, people with multiple chronic
diseases are often the least able to afford health cover.
• They may have some access to primary health care, but little
access to referral based specialists or inpatient care,
• Or access to inpatient care only in life threatening
• With comprehensive access to health services, they may be
subject to turf battles over whether GPs or specialists ‘own’
the patient.
• Inter-specialist referrals may fragment care, lead to
unnecessary investigations, and reduce the role of primary
care physicians.
• In conflicts between busy inpatient units with each trying to
‘disown’ the patient in emergency that clearly requires
Current problems in health service
• hospital-centrism reduces access to primary health care
• In over-commercialized health systems, people with multi
morbidity are particularly prone to supplier induced demand.
• coordination between hospitals, primary medical care and
community services is difficult and inadequate.
• multi morbidity requires support from non-health sectors.
• participation in civil society is challenging, they may be
effectively disenfranchised.
• Their reliance on carers puts strain on themselves and their
carer, and there is potential for abuse.
• Support for carers is often lacking in health systems, even in
high-income countries.
Potential for health gain
• Given the increasing burden of non-communicable
disease and the sub-optimum state of health care
systems, there is widespread potential for health gain
• through improving the way hospitals link with primary
and community based care.
• This will require a shift on both sides from episodic
care toward coordinated, tracked or managed care.
• Hospitals and their associated health care services will
need to maximize their contribution to population
health gain for patients, not just curate their acute
support during inpatient episodes.
Doing comparative research in Canada
UN and WHO Policy Context
• Political Declaration on the Prevention and
Control of Non-Communicable Diseases (UN 2011
• WHO promoting a ‘patient-centred model to
coordinate management of chronic diseases from
prevention to palliative care, at all levels of the
health system, across institutional boundaries
(primary health care, social care in the
community, hospital services, emergency care)’
(WHO Europe 2012)
Pan American Health Organization
• Promote integrated health service delivery
networks for the organization of the response to
• They recognize the increasing intensity of service
delivery needed as NCDs progress and patients
acquire multiple diseases; and
• emphasise the importance of horizontal
integration between hospitals, primary health
care and community services including social
services through a people centred approach.
(PAHO 2011).
Analysing Health System Reform
Assemblage of the health system
An approach to reform
• Knowledge developments: from disease
specific to multi-morbidity studies
• Organisational developments: from service
centred to people centred care
• Financing developments: from incentivizing
throughput to continuity of care
Health system reform direction
Traditional assemblage
Emerging assemblage
Service centred management
Patient centred services
Reform Direction
Disease specific
Episode incentives
Continuity incentives
of multi-morbidity
Organizational Reforms
• Drive toward people centred models of care
supported at all governance levels and
recognised in accountability frameworks.
• Leading hospitals have expanded to offer a
broader range of services, including non-inpatient
referral based specialist services in medicine and
allied health, satellite clinics, and community
outreach services.
• Toward integrated management of regional
hospital, primary care and community service
Organizational Reforms
• The expanded footprint gives great scope to
support primary health care services, and
support health promotion efforts.
• need to reorient logistical efforts to make care
efficient and coordinated from the patient’s
point of view.
• Clinical information systems which operate
across settings provide formidable capability.
Now: Data illuminates Research and Management
Soon: Data illuminating all of health care
Reforming the Evidence Base
• Elucidation of common risk factors for
multiple diseases eg diabetes, atherosclerosis,
renal disease, depression
• Global Burden of Disease work (Murray Gates)
• Guidelines for the management of common
combinations of diseases involving multiple
organs and specialties.
• New strong measures of global well-being
Reforming the Evidence Base
• Research on Wagner Chronic Care Model
• Research on the Burden of Healthcare
• Research into soft technologies – better ways
of doing things, of cooperating, new systems
of care, improvements in communication.
• Is always conducted in-vivo.
• Requires dialogue and negotiation with those
being researched (patients as much as medical
Reforming Health Financing
• 50 years since the publication of Arrow’s analysis of
health insurance in 1963
• WHO has swung from disease programs (1950s-60s) to
Primary Care and Health for All (1970s-80s) to targeted
programs (MDGs) to Universal Health Coverage.
• UHC orients financing for care of multi-morbidity
toward continuity of care.
• But payment mechanisms to promote this are unclear.
• Financing programs often cause primary and referral
based care to dis-integrate.
Current Questions
• How can we accelerate integration between
primary and referral based care?
• What structural change will drive this?
Regional comprehensive care organisations?
PCOs? Private sector incentives/contracts?
• How should movement toward UHC be linked
to planned improvement in services?
• And what role does reform of governance in
the health system play in this linkage?
Chronic Disease Management in
Canberra Hospital and Health Services
CDM Register
Disease Audits
CDM clinics and services
Care Audits
Future directions
• Epidemiological and demographic transition
• Rising tide of chronic disease
• Diabetes, COPD and CHF account for the
majority of the ameliorable burden of chronic
• Government made the resource allocation
• Someone had to pull it together on the shop
floor of the health service jungle
Skating on Canberra’s thin ice
The CHHS CDM Register
On the MacColl Assessment of Chronic Illness Care Survey, our
Clinical Information System pulled the whole level of support
for the Chronic Care Model down to only the ‘Basic’ level.
CHHS CDM Register
• One of Canberra Hospital and Health Services’
clinical information systems.
• Patients discharged from the Canberra Hospital
with Diabetes, Chronic Obstructive Pulmonary
Disease or Chronic Heart Failure
• or received care from some of the services that
participate in the Chronic Disease Management
Clinical Network Includes case management
information for a range of clinical services.
CHHS CDM Register
• Hospitals ,like GPs, should know their CD patients
• and track the care provided to them.
• The CDM Register draws on CHHS data records
therapeutics and
Support for self management
• Highly compliant with eHealth and HL7 standards
Diabetes Management Audit
• 1029 CDMR patients with a HbA1c test
performed since 1 January 2010,
• 73% had their HbA1c checked in the previous
6 months.
• 40% of patients had a HbA1c less than or
equal to 7%
• Detailed, identified results provided to 12
service units, updated monthly
Kidney Disease Audit
• 2386 CDMR patients with an eGFR result since
Jan 2010
• 69% had a result recorded for the previous 6
• 30% have at moderate or severe loss of kidney
function (eGFR<60)
• Detailed, identified results provided to 12
service units, updated monthly
Nursing Team of the Year 2012
CDM Services
• Management consulting
Implementing the chronic care model
QI, Evaluation, student and registrar research projects
Budget submissions (eg Obesity Management Service)
We convene and support a CDM Clinical Network
• Home telemonitoring
Telemedcare monitors
Sick patients with multiple chronic diseases
Physiological stabilisation
Confidence for CD Self Management
Nurse-led clinics and services
• COPD CNC Service for frequent users of the acute
care sector with COPD
clinical support and
care coordination.
Smoking cessation clinic
• Close links to Pulmonary Rehabilitation Program
• Reciprocal support arrangements with
Respiratory physicians
Nurse-led clinics and services
• Parkinson’s Disease and other Movement
Disorders CNC Service
• Clinics at Canberra Hospital and University of
Canberra private clinic
• Apomorphine service with commencement in
Hospital In The Home
• Close working relationship with Neurologists
• Strong support from the ACT Parkinson’s
Disease Society
Nurse-led clinics and services
• Heart Failure CNC Clinic
– In parallel with Cardiologist Outpatients
– Phone and home visit followup available
• Heart Failure Rehabilitation Course
– Grew out of Cardiac rehabilitation course
– 12 weeks of exercise and education
• Heart Failure Inpatient Consult Service
– CDM supports cardiologists to provide this, and
use it as a feeder for the CNC clinic and HF course
Our friendly staff will sign you on for
trials, eHealth and special offers
Advance Care Planning Clinic
• All staff participate
• Preparatory discussions in the course of care
• then clinic booking made for decisions and
• Two staff, patient and carer all need to be
present for legal reasons.
Care Coordination Service
• For COPD, Parkinson’s and CHF
• Referrals assessed by CNCs
• Care coordinators develop Flinders Care Plans
with patients
• Focus on patient goals linked to self
management strategies, education and
coordination of community and other support
• Linkage to general practice is patchy
CD Telephone Coaching Service
• Telephone based service to improve self
management for people with
Chronic Heart Failure,
Coronary Artery Disease,
Chronic Obstructive Pulmonary Disease
Diabetes. The service is being delivered by an
• We have teamed with Medibank Health
• Referrals or CDM Register-based patient selection
• Single consent process
CDM Performance Monitoring
• Detailed performance monitoring for all
• Regular, one-off and research grade
comparative audits for each service using the
CDM Register
• Occasions of Service tracking from the Patient
Administration System
• HbA1c and eGFR from ACT Pathology
Audit of Care Plans for 2209 patients
on the CDM Register
Number of participants with any care plan and
with a CDM care plan
No. with any
care plan
No. with CDM
care plan
CDMR all
n (%)
CDMR other
n (%)
n (%)
n (%)
n (%)
2202 (100%)
1337 (61%)
325 (15%)
416 (19%)
124 (6%)
1423 (65%)
839 (63%)
234 (72%)
236 (57%)
114 (92%)
464 (21%)
216 (16%)
105 (32%)
45 (11%)
98 (79%)
Type of in-scope care plan
Total Care plans in all patients: % of total care plans per group
I nter- D is c iplinary C are P lan (6 5 0 1 0 )
G oal P lanning S heet / A C RS / RI L U C are P lan (6 5 3 6 6 )
Falls C are P lan (6 5 1 0 0 )
D is c harge Referral- V eteran's L ias on (6 5 0 0 5 )
C onferenc e / Family M eeting (6 5 2 9 5 )
Cardiac Rehab
C hronic C are P rogram C are P lan (6 5 2 3 0 )
C are P lan (6 5 0 0 0 )
C are C o-ordination and S ervic e P lan (6 5 2 3 5 )
A c ute Rehabilitation / RI L U C are P lan (6 5 3 6 5 )
% of t ot al care plans in group
Future directions
• We are working with the local Primary Care
• On integrating our Chronic Disease
Management Team with their Practice
Support Team
• Deepening our involvement with general
practice to include practice managers and
• Overcoming distrust on both sides
• Hospital Networks should know their patients
with chronic disease, track and coordinate
their care appropriately.
• Aggregate chronic disease management
services to achieve critical mass, visibility and
• Work closely with general practitioners
• Build in QI, research and performance
Thankyou !
• Go to and search for ‘Chronic
Disease Management’

Chronic Disease Management in Canberra Hospital and Health