iConnect Care
Chronic Disease Care Program
u
"Virtual Medical consulting are we ready or
able?“
u
A/Prof Ivor Katz
The St George Hospital Renal Department
Virtual Medical Consulting
Typical Care vs Innovative Care
The Radar
Syndrome
 Patient appears
 Patient is treated
“find it and fix it”
 Patient is discharged
or lost to follow up
… then disappears from
radar screen
‘CKD iConnect Care’
offers an alternate
approach!
Source Epping-Jordan, J. (2001).
"The challenge of chronic conditions: WHO responds." BMJ 323: 947-948.
Futurists outline alternate
scenarios for what health care will
look like in 2025…
ALEXANDRIA,Va. – By
2025, patient-doctor
relationships and
health care delivery
will look radically
different than they do
today, according to the
Institute for Alternative
Futures
World wide, effective prevention
and management of chronic
conditions requires an evolution
of health care ….
from “radar care” to “innovative
care”
Screening for Chronic Disease
=CKD = CAD = Integrated Approach
HIV/GN
Hypertension
Diabetes
Kidney
Disease
Stroke
CAD
Source: Healthcare Decision Making in the Western Pacific Region: Diabetes and the Care Continuum. Carol
Beaver. 2001
CKD and CVD share common Risk Factors = Chronic Diseases
i.e. Hypertension, Diabetes, Obesity, Hyperlipidaemia, Proteinuria
The Case for Integrated Chronic Disease Screening & Rx:
Coexistence of Morbidities in Adults in Australian Aboriginal
Community (n=315).
Renal , n=110,
or 35%
Obesity,
n=85, or 27%
19
24
5
7
Diabetes,
n=86, or 27%
3
18
11
6
43
16
5
Hypertension,
n=149, or 47%
12
28
12
9
Percent with one or more conditions including obesity
Community 1 30%; Community 2 57%; Community 3 70%
Kidney system makes round trip to Africa
•
SYDNEY, June 13 AAP - An Australian method of
promoting kidney health has made a 17-year trip to Africa
and back, picking up improvements along the way…..
Where does this story begin?
Ivory Coast
1996
African Association
Of Nephrology (AFRAN)
Meeting
(ISN) International Society
Of Nephrology
Sponsored Meeting
Wendy Hoy’s CDOP onTiwi
Islands
Darwin
Chronic Disease Outreach Programs in
Australia
Tiwi Islands
Darwin
Wadeye
Naiuyu
Broome
Wuchopperon, Cairns
TAIHS, Townsville
Borroloola
Woorabinda
Cherbourg
Bega, Kalgoorlie
Brisbane
Kambu Kambu &
Inala, Brisbane
Soweto, South Africa
Prof. Wendy Hoy – Menzies University Darwin &
University of Queensland, Brisbane - Australia
Community-Base Dialysis Starts and Natural Deaths in Adults
(18+ yr), Annual Rolling Average, mid 2003 (Tiwi Islands)
20
18
Number of People
16
14
Treatment Program Begins
Dialysis Starts
Natural Deaths
Program
Stops
12
10
8
6
4
2
0
Hoy et al. MJA 2005; 183: 305–309
South Africa
Soweto
CDOP
in Soweto
and
South of
Township
Area of Soweto (South Western Township ) –
Greater Johannesburg 3-4 million people
1999-2009
1.5km
Soweto
0.88km
Dumisani Mzamane African Institute for
Kidney Disease
2700 Beds in Hospital
Factors associated with CKD and CVD (Chronic
Diseases) in Transitional Communities
Communities are
at particular risk
for
cardiovascular
(CVD) and
chronic kidney
disease (CKD).
Traditional lifestyle
Disrupted
e.g. Colonialistation,
Westernised diets & lifestyle
High risk for Diseases
e.g. Obesity, HT, DM,HIV
Development of “Transitional” Communities
Now accepted…Screen People at risk
Eight major risk factors for CKD
Diabetes
High blood pressure
Age over 60 years
Smoking
Obesity
Family history of kidney disease
Aboriginal or Torres Strait Islander origin
Established cardiovascular disease
1 in 3 Australian adults is at increased risk of CKD
due to the above risk factors!
Kidney Health Check
Kidney Health Check
Blood Test
Urine Test
BP Check
Creatinine & eGFR
Albumin /
Creatinine Ratio
(ACR) to check for
albuminuria
Blood pressure
should be
consistently below
140/90 mmHg
If all 3 tests are normal then the kidneys are in good shape and need
only be tested again as indicated by the applicable risk factors
CKD CDOP
Program Model
LINKING PRIMARY AND
TERTIARY SERVICES
Specialist
Specialist
Centre
CNC
Educational material,
guidelines, algorithms for
testing and treatment
GP and Practice or
Nurse Practitioner
and
Connecting Care
Nurses
Primary Health Care Nurses/Clinicians or Health
worker or educator, also volunteers
(Wagner Chronic Disease Care Model)
Wagner Chronic Illness Care Model
South African Chronic Disease Outreach Program
Real Life Situation , No major intervention!
Program Methodology
Participatory Action
Factors affecting pt care and CDOP!
1. Community
Resources and Policies
3. Self
management
support
4. Delivery
System
Design
2. Health System
Organization of Health Care
5. Decision
Support
6. Clinical
Information
Systems
PRODUCTIVE INTERACTIONS
Informed
Activated
Patient
Prepared
Proactive
Team
Improved Functional and Clinical Outcomes
Wagner Chronic Illness Care Model. Changes in the health system will only improve
chronic illness care if active, informed patients work together with Provider teams
Good CKD Rx requires a Chronic Disease
Model of Illness Management = Difficult!
WHO
Innovative
Care
for
Chronic
Conditions
= ↓CKD = ↓ CVD
20 PHC Clinics
1 CHC South West of
Johannesburg
N
Chris Hani Baragwanath Hospital
specialist referral centre
5 clinics and 1 CHC south of
Soweto
CHC – Community Health Centre
Standard Health care clinic
SA CDOP Paper Based Method utilising PHC
Program Nurse Managers
Health Systems
Adaptation
Collect Data
Vital Link
•BMI
•Blood Pressure
•Random Glucose
Analyse Data
•HbA1c
With
•Cholesterol
Decision Support
•Proteinuria
Advise PHCNs
•GFR
Provide Feedback
Decision Support
Reports
Education
Training
Fup patients
Simple ‘Gate Keeping’ Approach to move
from primary and tertiary care
eGFR >60
➨ No proteinuria
➨
eGFR 60-90
➨ Early Proteinuria
➨
GFR <60
➨ Severe Proteinuria
➨
Go on with Care
in PHC
Caution –
continue to watch
in PHC
Refer Specialist
Training Basic Computer Skills and in the use
of the CIDOPP Application
Nurses and Doctors
learn critical skills on
CIDOPPP
Money form Khanyisa
Service Excellence Award
Grant
has been used to build a
Training centre
Why bring a CKD Chronic Disease
Program to Soweto to Sydney?
• Increased prevalence of CKD from education
•
•
•
and screening in Australia is placing increased
stress on the nephrologist
Gatekeeper issues controlling referral
Knowledge issues of who should be referred
Patients can stay in the community or with GP…
Donkey
Workload
Length of time to see Specialist
Australia's waiting lists for a specialist longest for
developed countries (OECD collated data 2010)
46% seeking a specialist appointment wait 4 weeks or
more
Compared with Germany (17%), Switzerland (18%), US
(20%), Britain (28%), Netherlands (30%) and NZ (39%)
STG Renal CKD Referral and Follow up
Evaluation Study
ANZSN Abstract 2012
► About 70% of referrals were for management of CKD
► Overall 53% back to GP within 8 months
► Most common investigations could have been
ordered in the primary care setting
iConnect Care CKD Module
SES Medicare Local
St George Renal Department
Central Database & Software Management
GP
Nephrologist
Practice
Nurse
General
Practitioner
Population
442 000
Specialist
Hospital Pharmacist
Community Pharmacist
Community
Nurse
iConnect Care System and Structure
Specialist Referral
& Review Centre
Control by CS Nurse / Consultant
St George and
Sutherland Hospital
Cloud
WWW
All linked through
Internet Network
Renal
Specialist clinics
Management based on
KCAT Protocols
SGH-TSH
Medicare Local
Divisions
GPs
Will communicate
&
Refer using Web
Private
to Public
Sutherland
Division
St George
Division
Patient Link
email/ or App
iConnect Care Web
Cloud Support
iConnect Care VMC
Central support & Data Base
Live July 2013
Specialists
Patient
Cloud
WWW
Primary Care
Clinician
Pharmacy
Virtual Education
Website
General
Practitioner
Primary Care Clinician
‘Virtual Education - iConnectED’
http://www.iconnect-care.com.au/
iConnect Care Online Forms
PROTOCOL FORM FLOW SUMMARY MODEL
ENROLLMENT
Registration
TREATMENT PHASE
Assessments/Meds/Labs
Opinions
Assessments
Case History Report
Annual, Follow-up, Unscheduled
Coordinator Query
Summary of last 4
Assessments/Meds/Labs
With Clinician Comments
Opinion
Eligibility
Demographics
Coordinator Query
Medication
Annual, Follow-up, Unscheduled
Coordinator Opinion
Consultant Opinion Review
Coordinator Query
Labs
Annual, Follow-up, Unscheduled
Clinician Acknowledgement
GRADUATION
REFERRAL
OUTCOMES
Graduation
Referral
Outcomes
•Specialist Referral
• Not Eligible for follow up
• Biopsy
• Stroke
• Heart failure
• Hospitalisation
• GFR <30
• ACR > 25+
•Death
• Lost to Follow-up
• Consent Withdrawn
• Other
Coordinator Query
Requires Patient Consent
and Clinical Eligibility
Clinician uses Annual, Follow-up, Unscheduled
Labs optional for Follow-up / Unscheduled
Assessments
Unscheduled Visit does not change regular schedule
Opinion form available after QA of 3 Ass. Forms
May request Unscheduled Follow-up, e.g 3months.
May authorize Labs, Meds
Decision to keep on CDOP / Graduate
Trigger points colour coded
Patient Terminated from
CDOP Program
iConnect Care Process Automation
2. Consultant
Opinion
Processes
Reports
Internet
Forms
3. Database pushes
forms, opinions and
authorizations to
clinics and
consultants
4. Analysis Data
and Track/report
on follow-up,
outcomes and
other
information
1. Enrol patients at GP
or at Hospital clinic
PLATFORM
Reports
What forms look like…
What opinion looks like…
FOLLOW UP PLAN AND RANDOMISATION
Primary and Tertiary Care
Low Risk
➨ eGFR >60
➨ No Albuminuria
Moderate Risk
➨ eGFR 45-90
➨ Mild Albuminuria
Highest Risk
➨ GFR <30
➨ Severe Albuminuria
Management based on KCAT Protocols
Go on with Care
Primary Care and
Regular monitoring
Caution & continue to
Watch in GP Practice
Or online
Randomise at High Risk
Web Referral to
Specialist
Online or face to face
Results to date….
• 68 patients have been recruited (female 63%),
mean age 69 years, for:
1.
2.
3.
4.
5.
•
Decline in renal function (54%),
Albuminuria (21%)
Uncontrolled hypertension (18%),
Symptom Control management (4%)
Haematuria (3%).
Results to date….
•
Referrals have also included specialist
opinions for Renal Symptom and Palliative
(RPCP) support, Cardiology review and
Diabetes management.
•
•
Time to complete review averaged 1 week
But 3 weeks if a second specialist was
consulted.
Virtual Consultation - Case Study 1
• 41yr old Female
• Uncontrolled HTN possible DM
• GP used virtual consultation to get both
nephrologist and endocrinologist opinion as
patient was refusing treatment.
• Patient has been treated for 12 months and had
confirmed type 2 diabetes on treatment.
• All investigation arranged virtually e.g. echo, 24
hour ABPM
Virtual Consultation - Case Study 2
• 88yr old Female
• Patient referred due to decline in renal function
against a backdrop of previous bladder cancer.
• Known to urologist and oncologist.
• GP elected quick consult online due to promised
turnaround time of 1 week.
• Nephrologist recommended face-to-face
consult, obstruction recognised, stents placed
and adjunctive management started on renal
SPCP pathway
• Died after 6 months of follow up
Are we able?
•
•
•
•
•
•
Accept an alternate paradigm of patient care
Create virtual clinics
Allocate time to do consultations
Billing system to support this model
Need nurse case manager (CNS/CNCs)
Link to existing services and integrate it into
chronic disease programs
• Education around change management
processes e.g. Virtual Education initiative!
Independent Evaluation Report in Progress…
• GPs reported that software needs development
• Still GPs reported high level of satisfaction and
system
• 75% said they would participate more actively if
it was easier to enrol pts
• 50% felt it did not diminish pt care and that pts
were satisfied to receive ‘virtual care’
• 85% of patient felt they were well managed and
80% reported being very happy with ‘virtual
care’
Independent Evaluation Report in Progress…
• 60% elderly pts >70yrs were happy to see pts
‘virtually’ and for pts 55-69yrs this was 70%
• Some younger pts preferred to have a face-toface consultation (hybrid!)
• 30% didn’t mind waiting to see a specialist in a
hospital but 75% preferred convenience of
online opinions.
Zakumi Consulting – Dr Gary Jacobson
iConnect Care
‘Virtual Medical Consulting’
MODULES
FOR CHRONIC DISEASE
CKD
HTN
DM
Proteinuria
↓
CKD
Module
iConnect
Care
All these diseases could used web based
System to improve management and
Connect care
IHD
CCF
↓
CARDIAC
CLINIC
http://www.iconnect-care.com.au/
We are able… BUT
?
Are we willing
South African CDOP iConnect Care CKD
1. Premiers Service
Excellence Award 2004
2. National Productivity
Award 2005
3. Khanyisa Service
Excellence Award 2006
CDOPPP
Thank you for listening…
The ‘St George’ Team
RESULTS
Evaluation Approach
Quantitative Clinical and Functional Outcomes
Clinical Data e.g. Blood Pressure, Cholesterol
= Empirical outcomes = Follow up over 2 years =
Better Blood pressure control ? = Clinic differences?
Triangulation
Questionnaire
Diary Recordings
1.
2.
3.
Fup visits to clinics – Focus Groups
Report Back Meetings
Program coordinator diary recordings
Analysis carried out using:
•
Atlas.ti Software
•
Thematic content analysis
1.
2.
Clinical Scenarios = Knowledge (MCQ)
Health Worker Motivation (Likert scales,
domains from an existing model)
3.
Demographics & Program evaluation
4.
Open ended comments
Analysis carried out using:
•
Descriptive, ANOVA. T-test, Linear
Regression statistics
•
Atlas ti –Thematic content analysis
Program Evolution Timeline – CDOP
Phase 1 – Pilot Program
January 04
2.
1st SA NCO joins CDOP
3.
Enrolment begins and protocols and standard
operation procedures developed
11.
CDOP Educational Manual Developed
& 2nd PHC ‘Report Back Meeting’ (Sept 04)
12.
CDOP Wins Premiers Service Excellence Award &
Phase 3 Web Development Begins
December 04
January 05
18.
‘Traffic light’ risk factor approach to assist up referral &
to assist with poor follow up challenge
19.
Assist Health Dept with Obesity Education CDOP recognises obesity challenge
Audit of clinical data
July 05
December 05
Phase 3 – Web Based Phase
10.
PHC School Joins CDOP Network
(October 04)
Cardiology Unit joins CDOP Network
(November 04)
13.
- CDOP recognizes need to train PHCs to initiate insulin –
organises training
- Start use of ‘CDOP stickers to improve
Follow up & Purchases 2 cars for NCOs
- Recognise focus on HIV CKD
15.
NKF brokers Rotary Sponsorship of PHC training in
Australia
20.
Poor patient follow up continues
- focus on stickers and log books to track patients
- focus on developing local clinic CDOP coordinators
instead of focus on all PHCs
- NCOs in Australia for training
23.
Active planning and development for CDOP web
phase with analysis of phase 2 challenges,
failings and successes
- Change management seminar
25.
- Questionnaire given to PHCs
- Web based module training
Begins
- 2 pilot web collection sites
established
Review Phase
22.
CDOP becomes ‘Referral Only’ program until
phase 2 closes – PHCs to detect on ‘Red Referrals’
or use CDOP for decisions support
February 06
8.
Australian NCOs return home &
Australian High Commission sponsors CDOP Office
and Educational Manual
Inception Phase
14.
2nd Jhb Metro Health Report Back &
3rd PHCs Feedback Meetings
(February 05)
July 04
Review Phase
7.
NCO computer training begins
9.
1st Jhb Metro Managements ‘Report Back’ Meeting
(July 04)
4.
Recognise need for 2nd NCO
Inception Phase
1.
Australian NCOs arrive to train and help
develop SA CDOP
Health System and Health Care
Team Challenges
no. of quotes
?
35
30
25
20
15
10
5
0
Further
Investigation
??
Kno
Wo
Wo
Qu
Abs
Tur
ali t
rk Q
rk Q
no v
e nt
wle
y
er
eei
d ge
a ul
u al
v
s
sm
ity :
ity
. Qu
de f
'Ba
Da t
an t
icie
ra s
a ca
ity
ncy
yn d
Car
ptu
rom
e
re
e'
Codes
Primary Health Care Nurse Turnover
Impacts on Program Implementation
Clinics
PHCs Start
Resigned&
Retired
Total
186
66
135
643
Average/clinic
9
3
7
32
Lowest
0%
Highest
75%
PHCs End
% Lost
Questionnaire evaluated Program Value
+ve
$ p<0.0001
NC vs. CD by
Χ2 testing, in
favour of CD
Evaluated Knowledge of ‘Ideal’ Targets
and impact of education
Knowledge Evaluation Serum Glucose Target
PHCN’s were not using HbA1c before CDOP
‘Ideal’ Blood Pressure targets of PHCNs
1%
Unsure
42%
<149/90mmHg
12%
<169/90
25%
<130/80mmHg
Knowledge Evaluation
Last Hypertension Targets Taught?
20%
<120/70
Questionnaire Results
Clinical Scenario
Scores (ANOVA)
• CDOP PHCNs Higher
scores p<0.0034
• Colleagues more
likely to ask a CDOP
PHC than call a
hospital for advice
Motivation Scores
Chi-Square Analysis
• Higher motivational
scores
• CDOP PHCs Less
likely to leave public
health sector
p<0.0754
• More satisfied in their
job p<0.0524
South African CDOP Patient Outcomes
N=618 (Phase II)
DETERMINE WHAT IS POSSIBLE WITHIN EXISTING CAPACITY
Sensitivity and Specificity of
Referral Decisions
Were
referred
by PHCN
or CDOP
Required referral
Yes
No
Yes 104
0
(true +ve)
No 6*
Total 110
Total
104
508
(true –ve)
514
508
618
CDOP/PHCN correctly refer patients to specialist centre
Sensitivity = Meet criteria and were referred = 95%
Specificity = didn’t need referral & not referred =100%
Sensitivity and Specificity of
Referral Process
Required referral
Arrived at
Specialist
Clinic
Yes
Yes 83
(true +ve)
No 27
Total 110
No
0
Total
83
508
(true –ve)
508
535
618
The specificity of referral process100% for those not
qualifying for referral
BUT
Problem with the program as Sensitivity = 75.4% i.e. not all
patients who should have been referred arrived at
specialist centre.