3. Chronic Diseases They are of long duration and generally
slow progression. Cardiovascular disease (Coronary heart disease,
Stroke) Cancer Chronic lung disease Diabetes Chronic neurologic
disorders (Alzheimers, dementias) Arthritis/Musculoskeletal
diseases Chronic mental illness Injuries, which have an acute
onset, but may be followed by prolonged convalescence and impaired
function
http://www.who.int/gho/ncd/mortality_morbidity/en/index.html (WHO,
2011)
4. Proportion of total Proportion by sex () 2009
5. ( ) 5
6. 6
7. Modifiable Risk Factor Chronic Diseases The WHO has
prioritized the following four: 1. Physical inactivity 2. Tobacco
use 3. Alcohol use 4. Unhealthy diets (WHO, 2011)
8. 2004 2009 0 200 400 600 800 1,000 1,200 Alcohol consumption
Tobacco smoking High blood pressure High BMI Not wearing helmet
Unsafe sex High cholesterol Low intake of fruit and vegetable
Physical inactivity Water, sanitation and hygiene Air pollution
Illicit drugs use Not wearing seatbelt Malnutrition DALYs('000)
2009 2004 8
9. 0 100 200 300 400 500 Mental and behavioural disorders
Diseases of the eye and adnexa Diseases of the genitourinary system
Diseases of the skin and subcutaneous tissur Diseases of the
digestive system Diseases of the musculoskeletal system and
connective tissur Endocrine, nutritional and metabolic diseases
Certain infectious and parasitic diseases Diseases of the
circulatory system Diseases of the respiratory system Rate per
1,000 populations 10 0 400 800 1200 1600 2000 Cerebrovascular
diseases Injuries to the neck Ischaemic heart disease Diseases of
oesophagus, stomach and duodenum Chronic lower respiratory diseases
Influenza and pneumonia Intestinal infectious diseases Renal
failure Diabetes mellitus Hypertensive diseases Rate per 100,000
populationsTotal Female 2012 10
10. Health insurance system research office, 2011 100,000
11. Designing and Developing Disease and Care Management
12. The goal of a disease management program for patients with
COPD is to provide the highest level of home care to patients with
this condition and to improve their quality of life
13. PROBLEMS IN HEALTHCARE Aging population Inability to
sustain current method of providing healthcare to those in need
Rising costs Decreasing numbers of healthcare providers Lack of
preventive care Societal attitudes Hospital readmission rates
14. THE VICIOUS CYCLE Chronic Respiratory Diseases PATIENTS
NEEDING HOME CARE ON DISCHARGE FROM HOSPITAL DISCHARGE PLANNING :
Effective communication and collaboration CONTINUUM OF CARE
EDUCATION FOR PATIENTS AND CAREGIVERS HOSPITAL HOME
EXACERBATIONS
15. What is Disease Management ? DMAA Definition
Multi-disciplinary, continuum-based approach to healthcare delivery
that: 1. Supports the physician/patient relationship and plan of
care 2. Emphasizes prevention of exacerbations and complications
utilizing cost-effective, evidence-based practice guidelines, and
patient empowerment strategies 3. Continuously evaluates clinical,
humanistic, and economic outcomes with the goal of improving
overall health
16. DISEASE MANAGEMENT ELEMENTS 1. Care management 2.
Prevention 3. Treatment of acute and chronic conditions 4. Pharmacy
management : Medication and devices use with education : Medication
adherence counseling 5. Specialty referrals 6. Self-management Proc
Am Thorac Soc Vol 9, Iss. 1, pp 918, Mar 15, 2012 . Copyright 2012
by the American Thoracic Society DOI: 10.1513/pats.201201-014ST
Internet address: www.atsjournals.org
17. DISEASE MANAGEMENT ELEMENTS 7. Oxygen management 8.
Pulmonary function testing 9. Tobacco Cessation 10.Transition to
home planning Follow-up visit at home by Transition Coach Proc Am
Thorac Soc Vol 9, Iss. 1, pp 918, Mar 15, 2012 . Copyright 2012 by
the American Thoracic Society DOI: 10.1513/pats.201201-014ST
Internet address: www.atsjournals.org
18. Shift focus from acute care to chronic care involving the
community and health system including education and support Wagner
EH. Chronic disease management: what will it take to improve care
for chronic illness? Eff Clin Pract 1998;1(1):2-4.
19. Expanded Chronic Care Model COMMUNITY ORGANIZATIONS
HEALTHCARE ORGANIZATIONS Self Management Support Decision Support
Delivery System Design Clinical Information Systems Informed
Activated Patient Activated Community Prepared Proactive Practice
Team Prepared Proactive Community Partners Productive Interactions
& Relationships Improved Health and Functional Outcomes . .
NETWORK Offer proven, effective programming Outreach to &
engagement of high risk populations Provide gap-filling and linkage
services Increase access to benefits and services Advocate for
policies that improve health Victoria J. Barr, Sylvia Robinson,
Brenda Marin-Link, Lisa Underhill, Anita Dotts, Darlene Ravensdale
and Sandy Salivaras.
20. Delivery System Designed to Provide Planned Chronic Care :
COPD 1. Team including a skilled health professional case manager
2. Continuous communication to effectively manage COPD in it
trajectory 3. Properly trained professionals to support physicians
and patients 4. Therapies supported by protocol (evidence-based
practice guidelines)
21. Self-management skills and healthy behaviors
22. The Community Care Disease Management Build capacity for
routine assessment Reduce unintended variation in care, and
establish consistency of care Build capacity to educate patients,
families Report outcomes and process measures to all
23. 1. Use of information systems to access key data on
individuals and populations 2. Identifying patients with chronic
disease 3. Stratifying patients by risk 4. Involving patients in
their own care 5. Co-ordinating care (using case-managers) 6. Using
multidisciplinary teams 7. Integrating specialist and generalist
expertise 8. Integrating care across organizational boundaries 9.
Aiming to minimize unnecessary visits and admissions 10. Providing
care in the least intensive setting Good chronic disease
management
24. Chronic Respiratory Diseases Management And Health
System
25. Framework for Achieving Chronic Disease Prevention and
Management Burden of Chronic Illness Chronic Diseases Morbidity
Mortality Prevention Dividend 1. Risk Behavior Reduction 2. Social
& Physical Environment Inequity Prevention Interventions
(Primary, Secondary, Tertiary) W.H.O. Innovative Care for Chronic
Conditions, 2002
26. Health Service Delivery System Chronic Illness Conditions :
Respiratory Diseases Activated / Informed patient and caregiver
Prepared / Proactive care team Payer . / . / . Service Delivery
Design Easy Special HC Provider Local Community Industries . Health
IT System Social Network mobile devices Associations Population
Health Mnt. Care mng. / wellness / dz. Mnt. Distribution Medicine
Medical Devices : Diagnose, 1ry 2ry Prevention
27. Lifestyle interventions Low risk At risk Disease Management
DiseaseSymptomsEarly Signs Preventive Services Case Management
Screening Primary and Secondary Prevention Acute treatment Disease
Management HEALTH IMPROVEMENT DISEASE MANAGEMENT HEALTH MANAGEMENT
POPULATION-BASED CASE-BASED
28. Chronic Respiratory Conditions
29. HOME HEALTH CARE Fitting People to Health Care in Their
Home Environments Caregivers: Family, Friends, Formal Caregivers
Medical Devices and Equipment, Long-acting B2- agonists (LABA)
inhaled corticosteroids (ICS) Information Communication Technology
Perceptual, Cognitive, and Psychomotor Capabilities of Users
30. Spirometry: A Key to Early Detection of COPD Spirometry in
primary care setting is crucial Simple, inexpensive, office-based
Consider every smoker (past and present) Decline in lung function
is often undetected Patients may be asymptomatic or may
unconsciously modify activity to compensate Identification and
aggressive intervention can improve prognosis
31. 6 (6 Building Blocks) -- / & : & Source: World
Health Report 2007
32. . (1) 2015 2014 Improving quality of health care; primary
health care services Referral systems Harmonization of health
insurance schemes Emergency medical services Health promotion and
disease prevention for elderly and palliative care Services for
disables and underserved groups Herbal medicines Improving
emergency medical services in response to traffic accidents during
public holidays Improving quality of health care (reducing waiting
time and waiting list) Improving the management and allocation of
health personnel (human resources for health) Promoting and
supporting care for different groups including children, women,
elderly and underserved groups (project EWEC) Promoting and
supporting sustainability of drugs, vaccines and medical devices
Prevention and treatment for substance use disorders 34
33. . (2) 35 2015 2014 Developing and supporting global health
Supporting family physician policy Management of communicable
diseases and health threatening conditions Integrating health care
systems for cancer patients Health promotion and disease prevention
according to age groups Health promotion and disease prevention
according to age group focusing on high burden diseases such as DM,
hypertension Supporting research on health problems and health
system Review and evaluate DPL project Promoting governance in
health sectors
34. 2551 36
35. Service Delivery Reform Health System People Centered World
Health Report 2008
36. New kinds of practitioners Family physicians Formal
training (3 years) In-service training (3 years) 80 83 Family
Practice Learning (1 year)
40. The interdependence of the constituents of primary care
showing the centrality of the patient-clinician relationship in the
context of family and community and as furthered by teams and
integrated delivery systems. 21 + +
41. E mail [email protected] facebook : Morchuchai Line ID :
chuchai55
