Developing Chronic Conditions Policy and Measuring Impact in Wales Integrated Model and Framework fo

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Developing Chronic Conditions Policy and
Measuring Impact in Wales Integrated Modeland
Frameworkfor Action in WalesHelen HowsonWelsh
Assembly Government Sept 2007
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What, When and How ?

• Determine priorities
• Assess needs
• Collate and analyse evidence
• Formulate response and direction
• Consult with stakeholders
• Realign resources
• Implement change
• Monitor progress
• Evaluate impact

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Where do we want to be?

• We want
• world class health supported by world class
  health and social care services
• to prevent or delay chronic conditions
• to manage chronic conditions in an integrated way
• coordinate the management of core needs (i.e.
  housing, social support) and more specialist care
  in a simple and efficient system

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Making a difference

• How will we know if we got there
• What worked and what didnt
• Did we get the process right or not
• What were the outputs
• What impact or outcomes did we make a
  difference?

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Priorities

• The WHO has identified that managing chronic
  conditions is the main healthcare challenge for
  the future.
• In Wales, as with many other developed countries
  across the world, we have an increasing
  prevalence of chronic conditions, replacing the
  communicable and killer diseases of the past.
• This will be compounded with an increasingly
  aging population which will have a significant
  impact not only on health but upon a wide range
  of areas including the economy, employment,
  transport and housing.

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Birth rate and Population trends
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Population Pyramid 1961--------------2036
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Newid patrwm gwasanaethau Changing the pattern
of services
cydbwysedd newydd a new balance
gwasanaethau ôl-aciwtpost acute services
gwasanaethau cyn-aciwt pre-acute services
gwasanaethau ysbytai aciwt acute hospital services
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Purpose of the Model and Framework

• To set out a clear coordinated and consistent
  strategic direction for improving the management
  of Chronic Conditions in Wales, providing
• Evidence based approach
• Clear focus and direction
• Basis for measuring impact

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Aim and Objectives

• AIM
• Improve health and well being in the population
  and reduce the incidence and impact of chronic
  conditions
• OBJECTIVES
• Promote wellbeing in the community
• Prevent and delay the onset and early
  deterioration of chronic conditions in the
  community
• Improve quality of life for people living with
  chronic conditions
• Deliver services and support closer to people and
  their communities
• Reduce the impact on secondary care, emergency
  admissions, length of stay and readmission rates
• Increase self management, independence, and the
  participation of people with chronic conditions
  and their carers
• Improve prescribing and medicines management
• Improve economic activity with increased return
  to work rate

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Chronic Conditions Management Framework for
Delivery
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What should we be measuring?

• Health trends morbidity mortality
• Services what / where
• Impact of services
• Changes to services
• Patients experience
• Resources

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WAO Survey 2007

• General figures
• 804,000 patient episodes
• 134,000 patient episodes attributed to chronic
  conditions
• 727,000 patient spells
• 111,000 patient spells attributed to chronic
  conditions
• 37 of patients admitted to hospital are aged 65
  or older
• Proportion higher (49) for those with chronic
  conditions
• 45 of those admitted with chronic conditions
  were admitted two or more times
• 4.56 million bed days utilised
• Of these 0.94 million bed days attributable to
  chronic conditions

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Chronic conditions as emergency admissions to
hospital

Fig 3 Chronic conditions as emergency admissions
to hospital

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Monitoring and Evaluation

• Establish a 3 year monitoring and evaluation
  framework of CCM with support from WORD (AWARD)
• Determine baseline process and outcome evaluation
  indicators
• National and Local evaluation Framework
• Building on and from QOF, WAO, PEDW and other
  relevant data

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Other RD Developments

• Gaps in patient experience how was it for you?
• Voluntary sectors role in supporting chronic care
  pathways
• Health economics opportunity costs?
• Action learning live model support

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Next steps

• Need to be clear about what information we need
  and why
• Community health and service information scoping
• Issuing Service Development and Implementation
  Plan
• Local CCM Action Plans March 08
• Requiring monitoring and evaluation