Close the loop

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An elderly patient is seeing a heart specialist for the first time. She shifts uncomfortably in her chair, eyeing the garish diagram of a heart on a laminated poster decorating the office wall. With a sigh, she launches into a recitation of her medical history. It’s a monologue she’s delivered before, as recently as last month when she visited another specialist. She spends a lot of time going from appointment to appointment. It’s tiring, and she wonders why her doctors, who treat her for several chronic conditions, seem to work in virtual isolation from each other, as if parts of a broken loop.

Capital Health has been working to improve situations like these over the past few years. Dr. Richard Lewanczuk, medical director for Chronic Disease Management at Capital Health since late 2004, knows better than anyone that the traditional silo-culture of medicine is hard to break, but he also knows that there is a huge willingness by care providers to find better ways to connect the wires of communication and improve patient care.

“For a long time our health care system has really been an ‘illness care’ system,” Dr. Lewanczuk explains. “In other words, you get sick and then we do something.” Hospital costs use up the lion’s share of health care dollars. “But chronic diseases drive hospital usage,” he says. “In other words, it leads to 60% to 80% of our health care costs.” Chronic disease management physicians such as Dr. Lewanczuk want to prevent or detect disease early, and intervene to prevent complications that bring people through the hospital doors. “It’s about being as proactive as possible.” But saying medicine should be proactive and making it so is a huge undertaking.

“We really have to turn this ship around,” Dr. Lewanczuk says. The old way of doing things had health facilities setting up clinics for every chronic disease and condition. The problem is there aren’t nearly enough specialists to look after all chronic disease sufferers. For example, 50% of people over age 65 have high blood pressure. One in four people will develop diabetes in their lifetime; 10 to 20% of people will develop heart failure. “The other difficulty,” Dr. Lewanczuk says, “is that most people who have a chronic disease will go on to develop more than one.” Attending a clinic that focuses on one disease may mean other conditions aren’t considered during treatment.

“So you end up going to three or four different specialty clinics, and everybody takes the same history and orders the same lab tests,” he says. One physician might start a drug that another thinks unnecessary or that interferes with another treatment. The goal of primary care is to focus on the patient in what Dr. Lewanczuk describes as “a more rational way.”

Of course, that rational way has always existed, but it lacks the necessary support to counter the patchwork management of chronic disease at a system-wide level. The underpinning of chronic disease management is the family doctor, who can localize care and offer treatment and support in the community. This care allows specialists to be specialists. “They can focus their attention on the tougher cases,” Dr. Lewanczuk says, “where family physicians need their help. Family doctors can generally manage 80% of chronic care cases.

“There’s an old saying that specialists treat diseases and family physicians treat people. Family doctors can prioritize treatments for patients with multiple chronic diseases; they can keep the patient’s social and family background in mind. They’re in a better position than a specialist to integrate all information into a treatment plan. A goal of enhanced primary care is to have the family physician regain the role he or she had 20 or 30 years ago.”

The only surprise Dr. Lewanczuk has had is the notable lack of opposition Ñ there is remarkable goodwill on everyone’s part.

“But we can’t simply expect the family doctor to suddenly take on this huge role, so our job in administering chronic disease management is to help provide the infrastructure and backup to do it,” Dr. Lewanczuk says. Part of primary care reform in Alberta is the establishment of Primary Care Networks, whose mandate includes chronic disease management. The networks offer family doctors resources, including funding on a per-patient basis, to hire staff to deal with chronic disease. The individual primary care networks can then hire the professionals they need, such as nurses or pharmacists, to deliver care.

“From the system side, we make sure the linkages are there when the family doctor needs to access specialty care,” he says. Resources such as lung function testing or rehab services would fall under this mandate, as would training for primary care staff. Community supports such as quit smoking and weight loss programs are part of the picture. Now, when a doctor advises a patient to stop smoking or lose weight, he or she can offer patient support tools.

Primary care takes a layered approach to medicine. If a person identified as at risk for diabetes can’t lose weight after participating in programs his or her physician recommended, they might be referred to a regional clinic with personnel who deal with obesity or to a physician specializing in obesity. Next, they might be referred for obesity surgery. “But it’s all part of one big system now, and information is freely exchanged,” Dr. Lewanczuk says.

That free exchange is facilitated by Capital Health’s detailed electronic records system. Now a patient’s medical history is available 24/7. “The goal is to provide continuity of care,” says Dr. Lewanczuk. Apart from helping patients, electronic records can also indicate health patterns in a region and guide staffing and other resource allocations to where, for example, diabetes is more prevalent. Electronic records can help with reminders to patients to let them know it’s time to book appointments.

The only surprise Dr. Lewanczuk has had trying to implement new chronic care practices is the notable lack of opposition. “Once people understand the principles behind it, there is remarkable goodwill on everyone’s part: the public, physicians and specialists.”

These principles are taking off around the world. Ironically, it’s affluent countries that are slow on the uptake. “Countries with fewer resources have had to start doing things differ-ently,” Dr. Lewanczuk says. But within Canada, Capital Health is a leader. “We’re further ahead than any other jurisdiction in terms of the breadth of what we’re doing and our involvement,” Dr. Lewanczuk says.

And that breadth of involvement and participation in primary care initiatives is all about working together to close the loop.