The challenge of chronic disease management

This is background information and comments from GPs and experts at the collaborative Care Cluster Australia launch.

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Chronic illness is the single greatest challenge facing health care in Australia as the population ages. For example:

  • More than 7 million Australians have a chronic illness, such as diabetes, asthma, osteoarthritis, cancer, coronary heart disease, stroke, chronic kidney disease, chronic lower back pain, obstructive pulmonary disease and mental illnesses, such as depression.
  • Chronic illness rates are growing as the population ages. 13.5% of Australia’s population were aged 65 years and over in 2010; compared with 8.5% in 1960.
  • Diabetes alone costs Australia’s health care system more than $3 billion per year. Non-health care costs, such as travel for dialysis, special diets and carer expenses are estimated to double this cost.
  • An estimated 4.1% of the population have been diagnosed with diabetes at some time in their lives.
  • The proportion of the population with diabetes has more than doubled in Australia between 1989-90 and 2007-08.
  • Despite government incentives, fewer than 25% of people with chronic disease are placed on care plans. Less that 5% of patients are tracked for adherence to their care plans.

About the Collaborative Care Cluster Australia (CCCA) project

The Collaborative Care Cluster Australia project is an initiative to develop a cluster of industry and research capability in collaborative care and supported by funding from the Victorian Government.

CCCA is led by Precedence Health Care, the creator of cdmNet, the core broadband service used by CCCA to manage chronic illness and link together the range of health and technology services provided by the other partners of CCCA. These partners include Cisco Systems, world leaders in communications and teleconferencing technologies; Fred Health, Australia’s largest provider of pharmacy systems; Bupa, which worldwide cares for over 33 million people across 190 countries; Diabetes Australia Victoria, the peak representative body for people with diabetes; the Royal District Nursing Service, the largest and oldest provider of home nursing and health care services in Australia; the Royal Australian College of General Practitioners, Australia’s largest professional general practice organisation; major providers of health services: Southern Health and the South Eastern Melbourne Medicare Local; and research organisations including Baker IDI, Monash University and CSIRO’s Australian e-Health Research Centre

How does cdmNet work?

cdmNet is an online service and software program that helps health care providers manage and optimise treatments for chronically ill patients. cdmNet supports the entire process of care. It creates individualised care plans, shares the care plan and health records across the care team and with the patient through an internet-based platform, produces and distributes documentation, provides patient reminders, monitors progress against the care plan, automatically schedules follow up and review and manages Medicare compliance.

GPs, allied health professionals and patients can access the patient’s record via a secure, encrypted internet-based login. This has the same security and protection used in internet banking.

The records are digital, reducing the paperwork and duplication of paper-based systems, and ensuring record keeping is always up to date. cdmNet also enables communication, referrals and reminders via email and text messages.

How does cdmNet pay?

GPs prepare and oversee chronic disease management plans for patients, funded by Medicare as part of the National Chronic Disease Strategy. cdmNet is a ‘fee for service’ package, with Precedence Health Care receiving payment for each care plan produced using the service. Consequently, the system pays for itself. There are no up-front costs for general practice or the patient. cdmNet also increases GP productivity by 250%. Regular users can increase their annual chronic disease management revenue by $35,000 per annum per GP.

A 2007 Productivity Commission report estimated better prevention and management of chronic disease could result in direct health care savings of $4 billion annually. While cdmNet can improve profitability and productivity for GPs, it also reduces the far greater costs of avoidable hospitalisation than can occur due to poorly managed chronic illness. cdmNet facilitates the more efficient management of chronic illness through the primary health care system, rather than the more cost-intensive hospital system, allowing hospitals to focus on acute health care.

About Precedence Health Care

Precedence Health Care Pty Ltd is a company that specialises in providing broadband-based disease management services for the chronically ill. Precedence Health Care was founded in 2006 by e-health pioneer Professor Michael Georgeff. Professor Georgeff is CEO of Precedence Health Care. He is also Professor in the Faculty of Medicine, Nursing and Health Services Research at Monash University. In the 1980s, Professor Georgeff was Program Director in the Artificial Intelligence Center at SRI International (formerly Stanford Research Institute). During this period, he and his team created one of the first implementations of an intelligent software agent, using it to help control NASA’s space shuttle during space missions.

In 1988, Professor Georgeff was invited back to Australia by the Prime Minister, Mr. Bob Hawke, to set up the Australian Artificial Intelligence Institute (AAII). As Founding Director, he established AAII as a world leader in intelligent agent technology and its application to solving a wide range of commercial and social problems.

Professor Georgeff is a Fellow of the American Association for Artificial Intelligence and a Fellow of the Australian Computer Society. In 1990, the Bulletin proclaimed Professor Georgeff one of Australia’s “national assets”, the only technologist among the fifty-five persons so recognised.

More at: http://precedencehealth

GP experiences

Dr Myrle Gray Campbell Town Surgery, Tasmania

Dr Gray is also President of the Rural Doctors Association Tasmania.

“I use it every day. I love it. It’s so easy to use”

“You can adjust it, add to it and put your own personality on to it.”

“The practice nurses love it.”

“Every time you open a patient’s plan you get reminders. It will say ‘Review required’ when needed. You don’t have to remember it. One patient might have five chronic diseases that we have to manage. This makes it much easier.”

“The patients like using the program and getting the reminders, too. They enjoy it. It gives them a sense that they’re on top of their care plan.”

“I have one 75 year old lady who told me that her son is getting her an iPad. She’s looking forward to accessing her plan on iPad.”

Dr Cameron Profitt Bannockburn Surgery

Cameron was part of the original Geelong pilot group and has been using cdmNet for several years as it’s evolved.

“This streamlining is really important with chronic diseases like diabetes.”

“It’s not just a GP who is involved. Care teams can have a diabetes educator, dieticians, podiatry (we do at least an annual check of foot sensation with diabetes patients) and so on. The program is easy to use and learn. It’s great benefit is that it helps check that everything is getting done that should be.”

“I’ve found cdmNet handy and useful for chronic disease management, and particularly the inclusion of allied care. It’s reduces the bureaucracy and time spent communicating back and forth.”

“cdmNet has definitely helped with including the allied health team. These days, there are few allied health professionals that aren’t using computers, so we can send them emails and so on. It makes referrals much easier and saves paper and office staff time. In the past, for a care plan you had to fax off a letter to an allied health professional or call them, and then document the response. Now you just approve a plan and an email is sent to the team.”

“There’s also the capacity to do the home medicine reviews through referrals to local pharmacists. The report is sent back to the GP. This is particularly important as patients don’t always know or understand the names of the medications they’re taking. They might be taking the same drug twice under different brand names.”

“The fact that it does simplify the general practice management of chronic illness makes it worthwhile. There is a cost involved, but even if you’re paying a portion of the consulting fee for the use of cdmNet it’s worth it because you save so much time.”

Dr Tim Owen West Heidelberg Medical Clinic

“If you have a number of people involved in the care, then a centralised plan and information pool means that everyone has an idea of who is doing what. There is less duplication. There’s also the opportunity for the care team to reinforce that things that the patient can do, such as maintaining blood pressure control or an exercise program.”

“The information is important for a patient. It might be details of exercise needed, diet instructions or the need to reduce alcohol intake. Patients could also see their pathology results and how well they’re tracking against their targets. Ultimately, patients can get more involved in their own health care. Between appointments, they could be putting their own measurements or readings in.”

“The program is good for follow through and reviews. In the past, they would happen in a more ad hoc nature.”

“Eventually it will become like a live medical record. It has great potential, for example, if someone ends up in hospital. The trouble with hard copies is they go out of date. I can see the benefits of accessing a live plan.”

Expert comment

Chronic disease management and the e-health revolution both involve the collaboration of a wide range of experts and stakeholders. We thought it might be helpful to provide a round-up of diverse views and quotes from supporters and key players in the Collaborative Care Cluster Australia project.

Professor Paul Zimmet AO Director Emeritus and Director of International Research, Baker IDI Heart and Diabetes Institute.

“Good communications is critical as the majority of diabetes sufferers need a team of care providers that should include their GP, an ophthalmologist, dietitian, podiatrist and pharmacist. cdmNet links all members of a care team and is the best technology tool currently available.”

“We now know there’s 1.5 million people with diabetes and a further 2 million who are pre-diabetic (at high risk of developing diabetes). The indications are that by 2020 diabetes will be the number one disease in men, and second only to breast cancer in women. Because diabetes is such a complex and chronic illness, you need a coordinated team of professionals to help ease the personal and national impact of this growing burden.”

Professor Leon Piterman AM Pro Vice-Chancellor (Berwick and Peninsula), Monash University. Monash University conducted independent trials of cdmNet.

“General practitioners aren’t managing diseases, they’re managing people. Effective health care requires an understanding of the biological aspects of the condition or conditions, but also the psychological and mental health challenges, and the social consequences, such as the inability to work or difficulty with the day-to-day living tasks. The GP becomes a manager, overseeing these various aspects of health care. It’s very hard in the current system of health care to do that alone. It requires a team care approach.”

“What cdmNet has done is provide an efficient clinical information system that makes health records available and accessible electronically. This supports the GP’s decision making. It also provides a delivery system for information sharing and feedback with the care team. It ensures the team is working cohesively.”

“The system was first trialled in Geelong with diabetes patients. Following that, it was trialled in Melbourne’s South East, involving 7-8 chronic illnesses. Monash University’s role has been to evaluate it. We’re now able to demonstrate that it improves adherence to the care plan and follow up of the plan. This leads to definite improvements in the control of diabetes, blood pressure, blood sugar, blood lipids and so on. We are seeing improvements in the clinical condition of diabetes patients and cardiovascular risk factors associated with diabetes.”

Professor Greg Johnson National Policy Director for Diabetes Australia, the leading charity and peak consumer body working to reduce the impact of diabetes.

Diabetes Australia works in partnership with diabetes health professionals and educators, researchers and health care providers to minimise the impact of diabetes on the Australian community.

“Living with diabetes and managing diabetes is a very complex and difficult thing.”

“Diabetes is serious and only half of Australians living with diabetes are achieving optimal blood glucose levels, which means they are at a higher risk of developing complications. Diabetes is associated with numerous complications which affect cardiovascular health, kidneys, eyes and feet.”

“Findings from the recent study of 3300 Australians by The Australian Centre for Behavioural Research in Diabetes found there were serious levels of diabetes-related distress, anxiety and depression in the everyday lives of Australians with diabetes.”

“We also know the health care system can be difficult to navigate due to the complex needs of people with diabetes.”

“The new health tool cdmNet focuses on the person’s total health needs and connects them with their health care team assisting them to receive the correct information and the appropriate health checks in the right time frames. This helps people with diabetes to live well with diabetes and have good clinical outcomes.”

Paul Cohen Deputy CEO of Barwon Health, which has been involved since the trial of cdmNet for diabetes care in the Geelong region.

Paul provides the perspective of the hospital system.

“We have a health care and hospital system that historically was designed to deal with acute health care problems. But as people live longer and we have an aging population, there’s been an explosion of people with chronic diseases, often with multiple conditions.”

“Chronic disease, such as diabetes, is best managed through the primary health care system in the community. Otherwise we end up with large numbers of people being hospitalised because their condition hasn’t been adequately managed in the community. Patients coming in with chronic diseases often have more complicated care and longer hospital stays, ultimately pushing out people waiting for elective surgery. What we’re seeing globally is escalating hospital costs, which swallow up government health budgets. What cdmNet does is manage these conditions in the community far more effectively for the patient and also in a much more cost effective way.”

“cdmNet offers the health care system a way to manage this explosion of chronic disease, rather than just having everyone ending up in hospital. If a patient with Type 2 diabetes has a GP managing their care plan with cdmNet, they’re more likely to see an ophthalmologist for eye care and a podiatrist to check their feet, rather than ending up in hospital going blind or having an amputation.”

“What we’ve seen with cdmNet is a very fast uptake of the program by GPs, but instead of the care plan just sitting in their system it makes linkages with the broader care team. This allows real time messaging and the building of a care team around the patient. It also allows the GP to monitor the care. For example, they will know if and when the patient has seen a podiatrist. And it’s a far better outcome for the patient to not end up in hospital, or lose a foot or go blind.”

Jason Trethowan CEO of Barwon Medicare Local

This is one of Australia’s 61 Medicare Locals, established to coordinate primary health care services beyond general practice to include allied health professionals, such as optometrists, physiotherapists, dieticians and pharmacists. Barwon Medicare Local was involved in the development of cdmNet.

“cdmNet offers a more efficient way for general practitioners to liaise with other members of the care team, particularly those that are outside the general practice. For example, if a dietician or podiatrist operates out of their own separate rooms, they’re still able to access and operate off the same information base as the GP. It’s a lot more efficient use of resources and encourages a genuine team process for supporting chronic conditions. It’s a tool that, once the general practice team is engaged with it, is a real winner.”

“Barwon Medicare Local has been involved with cdmNet for close to four years now. We’ve had clinicians involved in the design of the system, providing feedback through its development. They could see a real need for a shared record with the patient and other providers, making sure everyone is on the same page.”

“Ultimately care plans are about setting goals for patients and monitoring the patients’ ongoing progress. It’s important that care plans aren’t just generated, but that they have goals that are continually in front of the patients and their care teams.”

“cdmNet does reduce the need for manual or complicated ways of making records. It drives efficiency for the GP, does the paperwork, helps prepare billing and frees them up to spend more time with the patient.”

Stan Goldstein Medical Director at Bupa, one of Australia’s largest health insurance providers.

“Meeting the demands of chronic disease is fast becoming the single biggest issue in how health care is being delivered and provided. More and more money is being spent trying to manage chronic conditions by a system that was designed to manage acute problems. Bupa is really keen to help redesign processes that will help deliver care for chronic conditions more effectively. That means healthier people and more affordable health care.”

“The attraction I see of cdmNet is that, through a technological solution, the care team is brought closer together in a planned working environment. That’s been a problem in the past. It avoids team members having to struggle to work out what the other care team members are doing each time they see a patient. It has the potential to bring about a more sustainable health system.”

Professor Mark Cooper Deputy Director of Baker IDI Heart and Diabetes Institute, a CCCA partner.

“We’re in a world with increasing older people and more complicated diseases, but these are diseases we have treatments for and can manage.”

“In managing chronic diseases, we’re faced with complex pharmacotherapy, multiple referrals and potential complications. We need a system that helps the doctors to deliver patient care that results in better outcomes, less morbidity and greater convenience for the patient.”