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Chronically Well!

Concerto Health Capsule
Spring 2013

How can your region or health centre offer better primary health care, improve patient health and reduce the costs of all services for the population in the area? Many would say that such a formula is impossible, given the system’s budget situation, pressure from the growing demand for services, overcrowded emergency rooms, etc. False, say the health care systems experts. There is a way out of these endless situations, and it lies in providing optimal primary health care management for a population, with priority given to patients with chronic diseases. In the second issue of our Concerto Health Capsule, discover a starter kit for leaving the beaten path.

Managing chronically ill patients in a family medicine group

New system starter kit

The chronic disease management pyramid proposes categorizing patients in four levels based on their state of health. This model makes it possible to define services adapted to each of the four designated groups: healthy population, chronic disease patients, patients at high risk of complications, complex cases.

Below are five subsequent actions to carry out in order to implement this model in a structured manner and to go beyond merely identifying and managing frequent users who have already been hospitalized.

  1. Implement a training and coaching program for the interdisciplinary team responsible for the optimal follow-up for chronic disease patients.
  2. Provide interdisciplinary health care, based on relevant medical data and best professional practices, with priority given to targeted chronic disease patients – patients suffering from three or more chronic diseases and representing 25% of the adult population.
  3. Target and manage level 3 and 4 patients registered with a family medicine group (FMG) – often the frequent users of “heavy” resources – with individualized intervention plans, and manage complex cases as necessary.
  4. Measure the potential efficiency gains by analysing past and current use of CSSS services by CSSS patients and patients registered with an FMG, and the real savings that can result from providing services structured according to the chronic disease management pyramid.
  5. Make informed decisions and ensure strict accountability: dashboard to measure the care processes (appropriateness, access, continuity, quality) and the results obtained (patient state of health according to recognized standards, level of use of health services, improvement in lifestyle habits, etc.).

Would you like to proceed with caution?

In the next issue: maximizing your chances of success and identifying the strengths and weaknesses of your environment and the FMGs in your area before implementing an action plan for chronic disease patients.

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