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Chronic Illness A New Model of Care

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Kayla Brodkin MD Department of Gerontology and Geriatric Medicine Puget Sound Veterans Administration Health Care System Questions to ponder .. What do I expect ... – PowerPoint PPT presentation

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Title: Chronic Illness A New Model of Care


1
Chronic Illness A New Model of Care
  • Kayla Brodkin MD
  • Department of Gerontology and Geriatric Medicine
  • Puget Sound Veterans Administration Health Care
    System

2
(No Transcript)
3
Questions to ponder..
  • What do I expect this course to be about?
  • What skills do I hope to acquire during this
    rotation?
  • How will the skills I learn from this course help
    me to become a more complete physician?
  • What is chronic care-and why do I care?

4
What is Chronic Care and Why Do We Care Anyway?
  • Demographic estimates 99M Americans live with
    chronic illness, most with gt1 chronic illness,
    88 of gt65y have gt1 chronic disease, 25 of which
    have gt4
  • Projections of increased complexity of care in
    future
  • Aging and improved medical therapies contributing
    to increased prevalence, severity and complexity
    of chronic disease in US
  • Chronic illness accts for 75 national health
    care costs

5
Chronic Disease the transformed patient
  • Requirements for continuous care management
  • Continuity of care becomes cornerstone in
    management
  • Self-management increasingly required
  • Patient education key to promoting autonomy,
    responsibility and self-advocacy
  • Caregiver support increasingly important

6
Acute v Chronic Medical Care
  • Chronic Care
  • Continuous/dynamic
  • Non-curative
  • Co-managed (doctorlt-gtpatient)
  • Expanded care model
  • (case-management/multidisciplinary team)
  • Expanded sites of care and mode f/u
  • (hospital/clinic/snf/AFH/Asst Living/home
    telephone/email)
  • Evidence supports improved
  • morbidity/mortality/satisfaction/QOL/cost
  • Acute Care
  • Episodic
  • Curative
  • Hierarchical (Doctor-gtpatient)
  • Single care provider
  • Single site of care
  • Outcomes evidence

7
Chronic Diseases
  • HTN
  • DM
  • CHF
  • OA
  • COPD
  • Cancer
  • Mental Health Illness- depression/ dementia/
    psychosis etc
  • Chronic Infectious Diseases HIV/AIDS, Hepatitis

8
Changing Demographics in America
9
Traditional Approach
  • Clinical Presentation -gtDDX -gtTesting-gt
  • Dx -gtTherapeutics -gt Addl Testing -gtOutcome

10
Traditional Approach
  • Clinical presentation -gtDDX -gtTesting-gtDx-gtTherape
    utics-gtOutcome
  • hx
  • Cough Infection CXR PNA
    ABX Resolution
  • Dyspnea Ht Failure CBC
  • COPD sputum
  • phys findings
  • Rhonchi
  • Wheeze
  • Fever

11
Chronic Care Approach
12
Chronic Care Approach
  • Increased Complexity- medical/psychosocial
  • Interdependent variables
  • Patient expectations and values (autonomy)
  • Requires individualized approach
  • Multidisciplinary
  • Resource intense

13
Chronic Care Model (Wegner 96)
  • Model of primary care for chronic illness
  • Improve management and outcomes
  • Group Health Cooperative- novel modalities for
    management diabetes
  • Requires rethinking of practice
  • Involves entire community (include resources) and
    policies (public and private)
  • Healthcare system (including payment str)
  • Provider organization

14
Chronic Care Model The Evidence
  • DM Improved measures of disease control (HgA1C)
  • CHF Decreased hospitalizations/Cost of care
  • Asthma Decreased hospitalization/cost

15
A Case 90 yo hospitalized with ACS s/p stent
placement whose hosp complicated by delirium and
chf now ready for discharge
16
Chronic Care Team
  • MD- managed medical aspect of care, medications,
    consulted hospital resources (anticoagulation
    team, VNS) and arranged for medical follow-up
  • Social Worker- developed strategy for discharge
    to bridge community resources (VNS, MOW),
    enlisted family support, arranged transportation
    (discharge, resume Access), facilitated lifeline
  • Physical Therapist- assessed falls risk
    gait/station
  • developed plan for strengthening LE and
    maintenance, arranged for home safety evaluation,
    issued equipt for home use
  • Occupational Therapist- assessed ADLs, provided
    equipt for home use (energy conservation)
  • Pharmacist- assessed meds for potential
    interactions, provided mediset
  • Nurse- homecare visit to f/u sx, phlebotomy, fill
    medisets and evaluate compliance, communicate
    with PCP and rest of care team

17
Issues for consideration
  • Patient preferences
  • Functional status- newly acquired weakness
    (decreased ability to transfer and toilet w/o
    help) permanent v transient
  • Availability of social supports
  • Patients ability to manage own symptoms
  • Availability of additional resources
  • Safety of returning to previous living situation

18
Case
  • Pt preference to return home to independent
    living
  • Weakness and ADL deficiency addressed by
    rehabilitation effort (10 d subacute stay TCU)
  • Anticoagulation and cardiac meds monitored by
    home care nursing (VNS)
  • Mediset provided, home venipuncture, sx
    surveillance
  • Enhanced involvement of family
  • Issuance of life-alert system for safety

19
Questions to ponder..
  • What do I expect this course to be about?
  • What skills do I hope to acquire during this
    rotation?
  • How will the skills I learn from this course help
    me to become a more complete physician?
  • What is chronic care-and why do I care?

20
SUMMARY 1 My definition of what chronic care is
about
  • Chronic care is an approach to the ongoing care
    of a patient with incurable, perhaps
    life-limiting disease that integrates healthcare
    modalities to understand, support and facilitate
    an individuals functional potential and quality
    of life that is attainable and consistent with
    realistic personal goals.

21
Summary 2
  • Skills inclusive of
  • Obtaining a functional history
  • Discussing bad news with patients and their
    families
  • Participation as a member of a multidisciplinary
    team
  • Comprehension of community services and
    alternative living situations for patients with
    chronic illness
  • And provide
  • Opportunity to participate, listen and reflect

22
Summary 3 My answer to why I care
  • Chronic illness is ubiquitous, ever increasing
    and realignment of healthcare resources to
    address the magnitude and impact of chronic
    illness on healthcare delivery and cost in
    particular and society in general is urgent

23
(No Transcript)
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