Policy by Pilot? Learning From Demonstration Projects for Integrated Care

HIV infection, a communicable disease, and noncommunicable diseases (NCDs) are among the major health concerns worldwide. An estimated 33 million people live with HIV, two-thirds of them in sub-Saharan Africa, where three-fourths of all AIDS-related deaths occur.

Introduction: Each Belgian township has inhabitants who suffer from dementia and this prevalence will continue to rise. Not only Belgium but also other European countries are facing this increase. In Belgium, on average 70% of people with dementia are living and receiving care at home. Policy Context And Objective: There are many services available for people with dementia. The organization of these services is however, highly fragmented and difficult to navigate. Additionally, the multidisciplinary integration and coordination is limited. In 2015, the Belgian government approved a plan called “Integrated Care for a better health”, which led to the development of 12 pilot projects that aim to provide high quality care and support to patients through the implementation of different actions. One of these actions in the Waasland regional project aims to target the challenges as described above through the dementia coaching approach. This approach was developed and implemented bottom-up since 2019, with the input of informal caregivers and the Alzheimer’s patient organization. Subsequently, in 2021 a similar approach was developed for people with Parkinson’s disease. Target Population: The action targets people who are diagnosed with dementia, as well as their informal caregivers in the Waasland region. In October 2022, already 216 families have received guidance from one of the regional dementia coaches. Highlights: The dementia coaching approach is a unique initiative that targets coordination of care across organizations. It aims to be the “missing link” through a multidisciplinary coaching team of both self-employed coaches and coaches employed by the different regional health care organizations. Their main task is to assist in navigating the regional health systems and organizations, by house and/ or telephone calls. The regional hospital is an additional partner of the project alongside the primary care organizations. The approach aims to improve the perceived quality of care as well as patient empowerment. The project is continuously evaluated and improved based on its user experiences. The coaches need to follow a mandatory training and participate in peer reviews to ensure that they share a quality-based vision and approach. Since dementia coaching receives state funding for the pay of the coaches, it allows the approach to be offered without additional costs for its users. This improves accessibility of care. Transferability And Conclusion: The dementia coaching approach is already being implemented for people with Parkinson’s disease. The approach shows possibilities to be transferred to other target populations as well (e.g. other chronic diseases) and could be useful for people with comorbidities. This option is currently being explored. Additionally, the approach has the potential to be implemented in other regions and/or countries that are willing to add this missing link. Key words: pilot projects – co-creation – dementia – chronic disease - integrated care

Systems are investing in workers who come from the communities they serve to meet patient needs that extend well beyond clinic walls.

A World with Fewer People with Diabetes Noncommunicable Diseases

There is no cure without care.

BackgroundPreventive health care represents the future for health care delivery in South Africa to improve management of chronic diseases as this has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. Individual person’s health is unique, as they move in and out of chronic and acute health care phases, there is need to integrate chronic and acute care constructs to improve continuity of care and maximize health and improve wellbeing. The aim of this study was to determine the perceptions and perspectives of chronic patients’ and nurses regarding chronic disease management in terms of barriers, facilitators and their experiences.MethodsTo meet our aim we used qualitative methods involving the collection of information by means of focus group discussions in Dikgale Health and Demographic Surveillance System (HDSS). All data was recorded, transcribed verbatim and analysed using data-driven thematic analysis.ResultsOur study showed that chronic disease patients have a first contact with health care professionals at the primary health care level in the study area. The main barriers mentioned by both the health care workers and chronic disease patients are lack of knowledge on chronic diseases, shortage of medication and shortage of nurses in the clinics which causes patients to wait for a long periods in a clinic. Health care workers are poorly trained on the management of chronic diseases. Lack of supervision by the district and provincial health managers together with poor dissemination of guidelines has been found to be a contributing factor to lack of knowledge in nurses among the clinics within the study area. Both patients and nurses mentioned the need to involve community health workers and traditional healers and integrate their services in order to early detect and manage chronic diseases in the community.ConclusionsNurses and chronic disease patients mentioned similar barriers to chronic disease management. Concerted action is needed to strengthen the delivery of medications at the clinics, improve the chronic disease knowledge for both nurses and patients by conducting in-service trainings or workshops, increase the involvement of community health workers and establish a link (through formal referral system) with traditional healers.

COPD 2020: new directions needed.

Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries

This pilot project was designed to determine the feasibility and effectiveness of an adaptation of the chronic care model applied to uninsured patients in a free medical clinic staffed by volunteer physicians. Of the 149 enrolled patients, 117 had hypertension, 91 had diabetes, and 51 had hyperlipidemia. Patients were enrolled in a chronic disease registry from March 1, 2001 through September 30, 2002 at the Salvation Army Free Clinic (SAFC). Two part-time registered nurses served as care managers providing disease-specific management using evidence-based guidelines. Consistent specialty consultation was available via phone, e-mail, or physician visit. Patient self-management was encouraged through collaborative goal setting. There were 40 patients lost to follow-up; 109 completed the study. A clinically significant improvement was obtained in at least one chronic disease for 79 patients. The chronic care model was a useful template for the delivery of effective chronic disease care to a group of uninsured patients at a free medical clinic.

BackgroundRemote monitoring (RM) is defined as the surveillance of device-transmitted outpatient data. RM is expected to enable better management of chronic diseases. The objective of this research was to identify public policies concerning RM in four European countries.MethodsSearches of the medical literature, the Internet, and Ministry of Health websites for the United Kingdom (UK), Germany, Italy, and Spain were performed in order to identify RM policies for chronic diseases, including end stage renal disease (ESRD), chronic pulmonary obstructive disease (COPD), diabetes, heart failure, and hypertension. Searches were first performed in Q1 2014 and updated in Q4 2015. In addition, in depth interviews were conducted with payers/policymakers in each country. Information was obtained on existing policies, disease areas and RM services covered and level of reimbursement, other incentives such as quality indicators, past/current assessments of RM technologies, diseases perceived to benefit most from RM, and concerns about RM.ResultsPolicies on RM and/or telemedicine were identified in all four countries. Pilot projects (mostly in diabetes, COPD, and/or heart failure) existed or were planned in most countries. Perceived value of RM was moderate to high, with the highest rating given for heart failure. Interviewees expressed concerns about sharing of medical information, and the need for capital investment. Patients recently discharged from hospital, and patients living remotely, or with serious and/or complicated diseases, were believed to be the most likely to benefit from RM. Formal reimbursement is scarce, but more commonly available for patients with heart failure.ConclusionsIn the four European countries surveyed, RM has attracted considerable interest for its potential to increase the efficiency of healthcare for chronic diseases. Although rare at this moment, incentives to use RM technology are likely to increase in the near future as the body of evidence of clinical and/or economic benefit grows.

Integrated care has long emerged as a viable approach to overcome deficiencies in the care management for people with complex health care needs such as chronic diseases, disabling conditions, serious mental illness, and medically fragile children and the frail elderly, while at the same time improving efficiency, quality and effectiveness of the health services provided.The focus thus has been on better coordination and integration among health care sectors to manage specific (chronic) diseases.However, it has become evident that in order to provide truly populationcentred services that improve population health, the scope of integrated care needs to be expanded to bridge the gaps not only within the health system, but also between the health and social systems, among others.Consequently, initiatives are emerging internationally that have a broader focus than integrating health care.These initiatives aim to integrate services across health care, prevention, social care and welfare, and are often labelled as population (health) management [1].For instance, in the Netherlands, several regional partnerships originated in which care providers, insurers and stakeholders like municipalities and representatives of citizens participate [2].Similar trends can be observed in other countries, like Germany (e.g.Gesundes Kinzigthal [3]), England (e.g.Torbay [4]) and the USA (e.g.Accountable Community Organization [5]), where initiatives have developed, which all take a population health management focus.The scope of these initiatives reflects a wide array of integrated care concepts.All concepts need to overcome common barriers and challenges in order to be successful.

The migration from legacy fee-for-service reimbursement to payments linked to high-value health care is accelerating in the United States because of new legislation and redesign of payments from the Centers for Medicare and Medicaid Services. Because patients with chronic diseases account for substantial use of health care resources, payers and health systems are focusing on maximizing the value of care for these patients. Because chronic liver diseases impose a major health burden worldwide affecting the health and lives of many individuals and families as well as substantial costs for individuals and payers, hepatologists must understand how they can improve their practices. Hepatologists practice a high-intensity cognitive subspecialty, using complex and costly procedures and medications. High-value patient care requires multidisciplinary coordination, labor-intensive support for critically ill patients, and effective chronic disease management. Under current fee-for-service reimbursement, patient values, medical success, and financial success can all be misaligned. Many current attempts to link health outcomes to reimbursement are based on compliance with process measures, with less emphasis on outcomes that matter most to patients, thus slowing transformation to higher-value team-based care. Outcome measures that reflect the entire cycle of care are needed to assist both clinicians and administrators in improving the quality and value of care. A comprehensive set of outcome measures for liver diseases is not currently available. Numerous researchers now are attempting to fill this gap by devising and testing outcome indicators and patient-reported outcomes for the major liver conditions. These indicators will provide tools to implement a value-based approach for patients with chronic liver diseases to compare results and value of care between referral centers, to perform health technology assessment, and to guide decision-making processes for health authorities. This review sets the groundwork for implementing a value-based, patient-centered approach to chronic liver diseases within a health system. (Hepatology 2017;65:1749-1755).

Health Systems Need to Transform Data Collection to Advance Health Equity.

India has a double disease burden of chronic infectious and non-communicable diseases (NCDs) like diabetes, cardiovascular diseases, cancers, chronic renal diseases, etc. The Covid-19 pandemic is putting a huge pressure and a profound impact on healthcare systems worldwide. According to WHO rapid survey, 122 countries reported that NCD services are disrupted. To assess treatment seeking behavior of patients with chronic diseases during Covid-19 pandemic a cross-sectional study was conducted among 174 patients with chronic diseases by telephonic interview at NEIGRIHMS, a tertiary care institute in the capital city of the north-eastern state of Meghalaya, Shillong. Of the total patients, 33.3% did not come for regular health visits to the hospital. Characteristics like age (≥60 years), low income (≤15000 Rupee per month), education (illiteracy) and place of stay (outside local district) were significantly associated with irregular health visits of the patients. Education on preventive measures of Covid-19 and improving chronic illness care services by the primary level health institutions including availability of essential drugs may reduce the loss to follow up among patients. Telemedicine services in the primary level health care centers can be used for availability of follow-up services during emergency situations.

Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services