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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
This book aims to redefine the requirements of an effective care for the chronic diseases, and their difficulties of implementation; to analyze the processes allowing to reinforce quality and to contain the costs and the expenditure related to this care; and to release the dynamic processes of development of an efficient care, the organisational forms and the corresponding strategies.
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Veröffentlichungsjahr: 2018
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Table of Contents
Cover
Title
Copyright
Acknowledgements
Introduction
1 The Challenge of Chronic Diseases
1.1. Chronic diseases
1.2. Management of chronic diseases
1.3. Organization of the health system and coordination
2 Some Alternative Schemes for the Management of Chronic Diseases
2.1. Cooperation systems at the initiative of professionals
2.2. Cooperation systems at the initiative of insurers
2.3. Chronic care model
3 Difficulties in Implementing Effective Management
3.1. Technical difficulties
3.2. Social difficulties
3.3. Cultural difficulties
4 Redefining Conditions for the Effective Management of Chronic Diseases
4.1. Quality of the activities involved in the patients’ management
4.2. Diversity and relevance of the range of care, services and skills that can be mobilized
4.3. Cooperation of actors and coordination of their interventions
5 Activities Specific to an Effective Management of Chronic Diseases
5.1. Nature of specific activities
5.2. Implementation and funding of specific activities
6 Dynamic Processes for the Provision of Efficient Care
6.1. Deadlock and efficiency
6.2. Care quality and costs
6.3. System size and costs
6.4. Funding of a collective system and fee-for-service
7 Lump Sum Funding, Efficiency and Development
7.1. Different lump sum funding methods
7.2. Overall capitation and development
7.3. Endogenous development limits
8 An Illustration
8.1. Presentation of the care network
8.2. Analysis of RSD operation and development
8.3. Illustration scope and limits
9 From Processes to Organizational Structures
9.1. An organized system
9.2. Coordination practices
9.3. Steering function
10 Contractual Relationship Configurations
10.1. Structuring relationships
10.2. Organizational configuration
11 Implementation Strategy
11.1. Two change concepts
11.2. The success of a doomed reform
11.3. Strategy elements
12 IS in Health System Restructuring
12.1. The unbalanced organization of the health care system
12.2. IS in the system organization development
12.3. Promoting IS
Bibliography
Index
End User License Agreement
List of Tables
2 Some Alternative Schemes for the Management of Chronic Diseases
Table 2.1. The chronic care model’s main recommendations
List of Illustrations
1 The Challenge of Chronic Diseases
Figure 1.1. Influence of the patient’s role on care
6 Dynamic Processes for the Provision of Efficient Care
Figure 6.1. Improvement process of the effectiveness of chronic patient management
Figure 6.2. Specific activities/efficiency relationships
Figure 6.3. Quality/size/efficiency dynamic relationships
7 Lump Sum Funding, Efficiency and Development
Figure 7.1. Capitation/development/efficiency dynamic relationships
8 An Illustration
Figure 8.1. RSD dynamic development processes
Figure 8.2. Potential reversibility of the RSD development process
11 Implementation Strategy
Figure 11.1. Development dynamic of a fundholder group
Figure 11.2. Reduced form of the development process of the fundholder groups
Figure 11.3. Development strategy through the system’s size
12 IS in Health System Restructuring
Figure 12.1. The health operator model [CHO 00]
Guide
Cover
Table of Contents
Begin Reading
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e1
FOCUS SERIES
Series Editor
Bruno Salgues
The Management of Chronic Diseases
Organizational Innovation and Efficiency
Pierre Huard
First published 2018 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms and licenses issued by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at the undermentioned address:
ISTE Ltd27-37 St George’s RoadLondon SW19 4EUUK
www.iste.co.uk
John Wiley & Sons, Inc.111 River StreetHoboken, NJ 07030USA
www.wiley.com
© ISTE Ltd 2018The rights of Pierre Huard to be identified as the author of this work have been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.
Library of Congress Control Number: 2017957895
British Library Cataloguing-in-Publication DataA CIP record for this book is available from the British LibraryISSN 2051-2481 (Print)ISSN 2051-249X (Online)ISBN 978-1-78630-171-0
Acknowledgements
I wish to make reference to the following French journals: “Pratiques et Organisation des Soins” and “Santé Publique”, for allowing me to use passages of text and figures used within articles [HUA 11a, HUA 11b, HUA 14].
I wish to thank my friend (and co-author of the articles above), Dr. Philippe Schaller, creator and manager of “Réseau de Soins Delta” and the health center “Cité Générations” in Geneva, Switzerland, for a long collaboration and without whom this book wouldn’t have come to fruition.
Introduction
This book details a general reflection on the management of chronic diseases1, and more specifically, the organizational forms that are likely to promote its effectiveness and efficiency. This reflection is based on the premise that chronic diseases are increasing in the morbidity pattern as well as the difficulties that the health system is encountering while dealing with this problem and thus seeks to define new care models.
An extensive literature addresses these issues; in most cases, it adopts an approach that is both descriptive and prescriptive. More specifically, it describes the characteristics of alternative forms (Health Maintenance Organization, Care Networks, Multiprofessional Health Homes, etc.) and gives recommendations on the conditions to be met in order to improve the quality of chronic disease management.
However, these descriptions and recommendations list conditions (required or sufficient?), but do not provide much information as to the way to practically implement them in order to obtain effective and efficient care schemes.
This is why, while subscribing to this research approach, particular attention is here given to the analysis of the dynamic change processes that are likely to help the development of these innovative schemes (ISs).
More specifically, the reasoning presented is divided according to the following stages: (1) situation and issues linked to chronic disease management: Chapters 1–3; (2) quality-effectiveness conditions for chronic disease management: Chapters 4 and 5; (3) the development dynamics of an IS: Chapters 6–8; (4) IS organizational structure: Chapters 9 and 10; (5) IS implementation and transformation of the health system organization: Chapters 11 and 12.
I.1. Situation and issues linked to chronic disease management
In this section, we will recall the place of chronic diseases, the specific requirements for their care and the unsuitability of traditional organization (individual medical practices and hospitals) to address them (Chapter 1). In Chapter 2, we will mention the different categories of experiences, recommendations and models seeking to develop organizational forms that are better suited to these treatments. In Chapter 3, we examine the technical, social and cultural obstacles for the adoption of these new forms.
I.2. Quality-effectiveness conditions for chronic disease management
In Chapter 4, we will redefine the quality of chronic disease management by differentiating: (1) the intrinsic quality of procedures, (2) the diversity and relevance of the range of care and services that can be mobilized in order to meet patients’ needs, (3) the cooperation capacities of actors and the coordination of their interventions. Then (Chapter 5), we will try to identify the activities helping to put the three quality conditions just presented into practice. These activities can be described as “specific” since they are absent or only play a secondary role in the operation of traditional schemes, even though they are fully part of care quality. These include, for example, prevention, patient therapeutic education, a cooperation–coordination management function, multiprofessional quality circles, medico-social services, etc.
I.3. Development dynamics of an IS
In Chapter 6, we will create a process combination model allowing for efficient management. Care quality and scheme size seem to play a significant part in configuring these relationships. In Chapter 7, we will complete the model by paying close attention to the funding issue, and by considering in particular how capitation lump sum funding makes an endogenous development possible for IS. Chapter 8 is dedicated to a slightly detailed illustration, in which we analyze the development of a scheme that implements some of the relationships presented in the model.
I.4. IS organizational structure
Chapter 9 will recall the main aspects of an organization and, in particular, the differentiation of the activities and their coordination, as well as the generic forms they help to build (markets, hierarchies, networks). Cooperation and coordination conditions are detailed, as well as the need arising from them for a steering function. Chapter 10 concerns the different types of relationships, especially the contractual ones, which are structuring IS. It also focuses on the area configurations drawn up by different densities of relationships and, finally, the organizational dynamics through the various forms of collaboration.
I.5. IS implementation and transformation of the health system organization
Chapter 11 will provide strategic information in order to develop an IS, which is illustrated with the example of the success of an initially doomed reform (the 1991 British reform). We will detail a development strategy linked to the size of the scheme, and the corresponding strategic management. Chapter 12 is devoted to the possible IS role as an intermediary structure in the desirable development of the system organization. Finally, we mention the measures, principles and obstacles related to the promotion of a reform, which is explicitly intended for the effectiveness and efficiency of chronic disease management.
Of course, the model presented does not claim to be the solution to all the problems posed by chronic disease management. By developing a simple analysis through stages, which is illustrated with practical examples, we propose recalling some options that are likely to usefully inform the debate.
1
The expressions “management”, “care”, “treatment”, etc., “of chronic diseases” mean an overall activity (medical, paramedical, public health, medico-social, etc., practices) in support of patients suffering from one or more chronic or psychosocial diseases.
1The Challenge of Chronic Diseases
Over the long term, the significance of acute diseases has decreased compared to that of chronic diseases in the morbidity structure. This shift is reflected by difficulties in the health system in treating these diseases in a way that is fully effective. In this chapter, we will recall the main characteristics of chronic diseases [ACT 10], care requirements and the nature of the difficulties to meet these requirements.
1.1. Chronic diseases
1.1.1. The burden of chronic diseases
The WHO defines chronic diseases as non-communicable diseases, long-term illnesses (LTIs) with a generally slow development [WHO 17]. According to the WHO, they are responsible for more than 63% of deaths in the world (2013), and the organization insists on the fact that eliminating the main risk factors would help to prevent most of these diseases. The main risk factors are linked to individuals’ behaviors (smoking, unbalanced diet, harmful use of alcohol, sedentary lifestyle).
In France, we sometimes estimate the number of people suffering from a chronic disease at 20 million [GRI 17], namely one-third of the population. However, this status can evolve, as some acute diseases become chronic ones, for example AIDS that was initially a mortal acute disease, which became chronic at the end of the 1990s. Some other diseases’ situation have transformed; diabetes, for example, benefitted from the discovery of insulin in 1921 and the prevention of complications, until an artificial pancreas is provided some day. Regarding chronic disease management, we talk about tertiary care. The first type of care (primary care) deals with benign acute diseases and the second (hospital care) deals with serious acute diseases. As the third type of care deals with chronic diseases, it should be an integrated (biomedical, educational, psychological and social) care, which is practiced as a team and coordinated between doctors, paramedical staff, administrative staff and social workers.
If we assimilate chronic diseases to 30 LTIs of the French Assurance Maladie (health insurance), we found in 2015, in this context, 10 million patients representing more than 16% of the total population. These 10 million patients were divided as follows: cardiovascular pathologies 35%, diabetes 25%, malignant tumors 21%, psychiatric conditions 13%. Multipathologies are frequent, since there is 1.3 pathologies per patient. One-third of patients have been registered for LTIs for 10 years or more.
Furthermore, the Assurance Maladie published a map of pathologies and expenditure, which indicates a sharp increase in chronic diseases by 2020 [AME 17].
1.1.2. Characteristics of chronic diseases
Among the numerous definitions of chronic diseases, we can recall the one provided by the authors of the Plan to Improve the Quality of Life of People Suffering from Chronic Diseases 2007–2011 [MIN 07].
Box 1.1. Characteristics of chronic diseases
Chronic disease is characterized by:
– the presence of a long-lasting physical, psychological or cognitive pathologic condition;
– a duration of several months;
– an impact on daily life including at least one of the three following elements:
- a functional limitation of activities or social participation;
- a dependence on a medicine, scheme, medical technology, device or personal assistance;
- the need for medical or paramedical care, psychological aid, adjustment, monitoring or a specific prevention that can be part of a medico-social care pathway.
The characteristics relevant for the analysis are seemingly as follows.
Chronicity, which first refers to the duration of the situation, and in this case means (1) that no cure is expected and (2) that the patient can live for a long time by adapting to the constraints imposed by the disease (treatments, refraining from some activities, modifying some living habits, etc.).
In the long term, the patient’s situation is not stable; it evolves and evolutions are usually negative. These complications can be, for the same disease, numerous and varied, worsen over time while not being fully predictable, become debilitating and greatly deteriorate the patient’s quality of life.
In many of these diseases, the patient’s behaviors play a very significant part, both in the appearance of the disease and its progression. These behaviors concern (1) compliance, namely the patient’s ability to regularly follow the prescriptions of professionals, first in terms of consultations, examinations, taking medicine, reference to other professionals and providers; (2) compliance also concerns the recommendations made by professionals regarding a more appropriate lifestyle (diet, physical activity, smoking, etc.); (3) the patient’s behaviors also depend on their understanding of the disease, as well as their psychological and social situation, which can itself be affected by the development of the disease.
In connection with the patient’s behaviors, some diseases are asymptomatic before complications make them apparent. (1) During this period of silence of the disease, the patient tends to underestimate its seriousness and is going to be reluctant to make the efforts and sacrifices required for care. (2) Furthermore, the asymptomatic nature can also result in a late diagnosis, which will sometimes only occur when a complication is identified. Thus, prevention, management and the patient’s reaction can be delayed compared to the development of the disease. (3) Under these conditions, it seems even more important to be attentive to risk factors in order to foresee the onset of the disease.
These few characteristics make the management of numerous chronic diseases hard. Since doctors cannot force patients to comply, they sometimes have to negotiate less demanding treatments with them. Some of these characteristics tend to be reinforced through a set of interdependent links and highlight the role of the patient behaviors.
Figure 1.1.Influence of the patient’s role on care
Thus, the patient’s behaviors influence the development of the disease according to their compliance level:
– when this compliance is not good, development is not good or earlier and more numerous and more serious complications are to be feared. (1) Complications may affect the patient’s psychological (anxiety, depression) and social (impact on self-image, on their relationships with others, on working life, etc.) situation with negative effects on their behaviors. (2) Complications can have a direct impact on behaviors either because they are going to persuade the patient to improve their compliance or, on the contrary, because the deterioration of their condition limits their abilities to react;
– behaviors can compound the difficulties of professionals to treat the patient and contribute to a negative development;
– the asymptomatic nature reinforces these links by disturbing behaviors and care.
This list of characteristics can be illustrated by the example of diabetes.
1.1.3. The case of type 2 diabetes
Diabetes is a metabolic disease linked to a defect or lack of insulin secretion, to insulin action abnormalities, or both, and which is reflected by a chronic hyperglycemia [MOR 12].
Diabetes can be treated, but up to now, cannot be cured. The objective of long-term management is to try to stabilize the patient’s condition by avoiding, delaying and limiting deterioration.
In fact, diabetes is a progressive disease likely to give rise to serious and debilitating complications. These micro- and macrovascular and nervous complications concern many organs: heart (heart failure, myocardial infarction), central nervous system (stroke), peripheral nervous system (neuropathies), kidney (chronic nephropathy, renal insufficiency), eye (retinopathy), foot (ulcerations). These complications can have extremely negative impacts on patients’ quality of life.
The patient’s behaviors play a great part in the development of this disease, in particular because, apart from potential genetic predispositions, the main risk factor is excess weight. Thus, compared to a medium built population, the incidence of diabetes is three times higher in the population of overweight people, and six times higher in that of obese people. Consequently, eating habits, but also physical activity or smoking, are going to have a high impact on the development of the disease. The fact that the patient complies with lifestyle recommendations, but also obviously with medical prescriptions (regular examinations, taking medicine, daily management of the disease), is a decisive aspect of care. This necessary commitment from the patient to care represents for them a permanent constraint, where their understanding of the disease and psychological or social situation can make it hard to comply with.
This difficulty is highly exacerbated by the asymptomatic nature of the disease, which at the beginning evolves in a particularly silent way according to the following stages: (1) the cells of the organism become resistant to insulin; this resistance is worsened by the excess of fat tissues (overweight and obesity) and produces hyperglycemia; (2) in response, the pancreas increases insulin production to reestablish a normal level of glycemia; (3) after 10 or 15 years, the pancreas becomes exhausted and can no longer secrete enough insulin to regulate blood sugar levels. This process explains late diagnoses, many being made at the time of the appearance of complications.
This lack of obviousness of the disease also explains why the patient underestimates the seriousness of their condition. As long as they do not practically feel the drawbacks, they do not really see the need to comply with the constraints of the recommendations and treatments. This situation shows that the patient’s information and education are crucial; it also shows why doctors sometimes have to negotiate with diabetic patients’ treatments that are suitable to their abilities of understanding and commitment [BAC 06].
1.2. Management of chronic diseases
Given their duration and partially unpredictable developments, chronic diseases require specific forms of care.
1.2.1. Complex care
During their development, many diseases can give rise to quite varied complications, as we just saw for diabetes with the different organs that are likely to be affected. As a result, care will also be varied and require different actors (means, skills, position). In the case of diabetes, the basic list is probably as follows: general practitioner (GP), diabetologist, chemist, self-employed nurse, ophthalmologist, cardiologist, podiatrist, dental surgeon, dietitian, psychologist, tobaccologist, physical activity coach, patient association, remote assistance service (sophia), social services, and finally the patient and those close to the patient.
During care, in order to identify the problems and inform the concerned actors, determine and carry out interventions, communicate results and the patient’s condition fluctuations, it is necessary to create, treat, provide and store a great deal of clinical, administrative and organizational information. In other words, care becomes a complex dynamic system. Controlling such a system would meet a significant required condition in order to obtain effective care.
1.2.2. Characteristics of effective care
From the examination of the main shortcomings of some treatments, we can associate an effective care plan with the following aspects: continuity, consistency, comprehensiveness.
