Wednesday, January 27, 2010

Chronic health care: delivery of services

A new publication, from Health Council of Canada, has come out for Canadians, the second bulletin in the Canadian Health Care Matters series entitled Helping Patients Help Themselves: Are Canadians with chronic conditions getting the support they need to manage their health?  

This bulletin is based on the 2008 Canadian Survey of Experiences with Primary Health Care, which measured the quality of health care as reported by Canadian patients, including those with severe  chronic conditions. 

Firstly, what is a 'chronic condition'? 
These are defined as: arthritis, cancer, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, high blood pressure, and mood disorders (including depression).

The study reports that 
  • 17% of Canadians between ages 17 and 44 have one chronic condition
  • 25% of Canadians between ages 45 and 64 have one chronic condition
  • but 43% of us between age 45 and 64 have one or more chronic conditions
  •  By age 65+: 72 % of Canadians have as least one of these seven conditions.
  For many they are underdiagnosed by Primary Health Care teams giving them short shrift; women, who are missed for high blood pressure and heart conditions; Native People with diabetes issues; the poor whose low-income situation put them at risk for diabetes and the ability to manage their health problems.

For many it is a dollar short, and a day late. It is only lately, that standards to evaluate FHT have been created. Phone 20 patients and ask how they were treated. Easy bit of work. Provide feedback. Talk to people at the College of Physicians. As with End-of-Life Care, we can measure results of interventions, provide feedback, and improve our services.

You'll find, like this report, than many patients were not given a treatment plan, treatment goals, information about the impact of their chronic health issues, where to go for more information, and what to expect as they decline in health, mobility, and agility.

Primary Health Care Teamwork result in patients taking responsibility for their health. This is the philosophy of Family Health Teams (FHT) in Ontario.
Impact B.C. has taken this lead:

A primary, but not exclusive, focus of our work is primary care and chronic conditions. Find out more Fresh Ideas Video

Transforming primary care in BC is all about improving care for patients. The Fresh Ideas video shows how physicians and others are changing the face of care in the province.

For many, their visits to their family physicians leads not to more information, but to a prescription for medicine, not information about how they are contributing to their own health care issues (the Military calls this a 'self-inflicted wound'). For many a referral to a support group, visits with specialists (e.g., dieticians),  community program information or a written list of ways to improve their health would provide an opportunity for education and change. That could include: weight loss, exercise, diet, lowering salt intake or cholesterol. According to the 2008 Canadian Survey of Experiences with Primary Health Care:

Every patient needs a treatment plan, more resource information, access to community servies, and many physicians are not taking the time to do this. This is the perfect role for the Nurse Practitioner, or the nurses attached to the FHT clinics.
According to this report:
  • 40%  of respondents with one or more chronic conditions did not have a treatment plan
  • 40% of patients with 3+ chronic conditions did not discuss specific ways to improve their own health.
The costs are astronomical. Government spending on health care per Canadian:
Formal health care influences 25% of results. The other 75% are barriers to good health previously cited in this blog, and cited in this paper:
  • income, education, circumstances in early childhood, social supports, genetic make-up, physical surrounding.
With monthly visits to physicians for newborns and babies, we can see the results of good primary care. Parents track birth weight, prevent malnutrition, get regular inoculations, take vitamins as prescribed, and keep on top of stuffy noses and infections. Seniors do not have this advantage, with barriers to health care including orphan patients (especially in retirement communities, retirement homes and LTC facilities -once a resident moves from home to a new town or city).

Now, when we visited our vet for kitten #3, we were handed a "Wellness Binder", which included a lot of information: the Clinic Philosophy (that of wellness and prevention of illness), the history of their practice, the clinic hours, and place for emergency care, the ames of all of the team members from vets, to assistants, groomers and managers, the policy on prescription refills.

 Included also:
  • places for the recording of dates of inoculations, a monthly wellness visit schedule, information on diet, exercise, equipment you might need, websites of note, typical household poisons, and what to expect during stages of growth. They offer seminars on house training, first aid, grooming.
This is where we need to head, with patients taking responsibility for their actions, and their health care plans, monitoring their blood pressure, for example, and seeking valuable information from the Primary Health Care Team, with timely responses, doable self-help activities, and human and physical resources.

It's not that we don't know about this model. The Improving Chronic Illness Care program, developed in the US in the 1990s, has much valuable information.

Slideshow of the Chronic Care Model and its evidence base  

Patient-focused, team-based health care will prevent Emergency Care visits to hospital, an understanding of our physical needs, and a saving in taxpayer dollars.

Health Council of Canada. (2010). Helping Patients Help Themselves: Are Canadians with chronic conditions getting the support they need to manage their health? Toronto: Health Council

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