Management of patients with multimorbidity: the perspective of primary care

Size: px
Start display at page:

Download "Management of patients with multimorbidity: the perspective of primary care"

Transcription

1 Management of patients with multimorbidity: the perspective of primary care Prof. François Schellevis MD PhD NIVEL (Netherlands Institute for Health Services Research), Utrecht & Dept. General Practice & Elderly Care Medicine / Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam

2

3

4

5 What I will talk about Introduction: definitions, epidemiology Relevance Management: experiences and evidence Concluding remarks

6 Comorbidity any distinct additional clinical entity that has existed or that may occur during the clinical course of a patient who has the index disease under study (Feinstein, 1970)

7 Multimorbidity the co-occurrence of multiple chronic or acute diseases and medical conditions within one person (van den Akker et al, 1996)

8

9 Multimorbidity (comorbidity) multiple diseases (2 or more) in the same patient usually chronic diseases

10 Overlapping concepts Fried et al, 2004

11 Epidemiology of multimorbidity not easy to establish rates depend on e.g. - setting - measurement method - number of disease (entities) and their level of detail - age groups

12 Epidemiology of multimorbidity

13 Epidemiology of multimorbidity Rule of thumb: among people with a chronic disease 65% of the % of the 85+ suffers from multimorbidity

14 Relevance of multimorbidity Diagnostic Therapeutic Care complexity Patient s perspective

15 Relevance of multimorbidity: diagnostic (1) Mr. Smith 69 years old 3 months ago AMI (hospitalisation) good recovery, rehabilitation programme medication: beta-blocker, ASA

16 Relevance of multimorbidity: diagnostic (2) Mr. Smith s surgery visit: Tiredness Sleeping problems Concentration disturbance What are the plausible causes?

17 Relevance of multimorbidity: diagnostic (3) GPs are less inclined to diagnose a depression in patients who already suffer from a somatic chronic disease (OR = 4.2) Nuyen et al. Psychol Med 2005

18 Relevance of multimorbidity: therapeutic (1) Mrs. Johnson 79 years old medical record: osteoporosis, osteoarthritis, diabetes type II, COPD, hypertension

19 Relevance of multimorbidity: therapeutic (2) Mrs. Johnson s EBM treatment: 12 different drugs in 19 dosages at five moments a day 14 different non-pharmacological treatment advices (rest, exercise, shoes, avoid exposure to allergens) nutrition: reduce intake of Na, K, lipids, cholesterol, Mg, Ca, calories, alcohol at least 5 doctor visits per year Boyd et al. JAMA 2005

20 Relevance of multimorbidity: therapeutic (3) What is the evidence for the combined treatment of 5 diseases? How feasible is this regime? What does mrs. Johnson think about this regime? What about her quality of life?

21 Relevance of multimorbidity: care complexity (1) Diabetes mellitus patients: risk for specialized care in 1 year Outpatient Hospital DM ref ref DM DM DM + 3 or more Struijs et al. BMC Health Serv Res 2005

22 Relevance of multimorbidity: care complexity (2) Use of health care services: the more chronic diseases, the more different health care services are being used (and the more health care providers are involved) Westert et al. Eur J Publ Health 2001

23 The patient s perspective Focus groups of patients: Treatment (incl. advices) is not feasible Which caregiver is the expert? Need for information More attention for emotional impact Better coordination and communication Heijmans et al. 2003

24 A patient with multimorbidity I really thought I was going crazy. It had an enormous emotional impact. When I was also diagnosed with diabetes, I had to pay attention to what I was eating and the use of insulin, but at the same time take my pills at the right moment. It was a mess. And I was so afraid of becoming hypoglycaemic. And because of my Parkinson s disease I had trouble injecting my insulin and getting the pills in the right boxes. Heijmans et al, 2003

25 The professional s perspective Lack of evidence for medical treatment Quality of care decreased Patient unsafety Health care organisation is disease-specific Poor information management Who coordinates? Heijmans et al. 2003

26 Intermezzo Conclusions so far Multimorbidity is the rule rather than the exception among older people with a chronic disease Multimorbidity is relevant in terms of diagnostics, therapy and care complexity Both patients and professionals experience problems What does this mean for the management of multimorbid patients?

27 als/prevention-chroniccare/decision/mcc/video/index.h tml

28 Challenges for health care Focus on patients with the highest needs Existing care programs Evidence of effective programs Multimorbidity in consultations Polypharmacy

29 Multimorbidity patients: subgroups according to health care use (N=20,167) Hopman P, et al. Eur J Int Med 2016

30 Multimorbidity patients: subgroups according to health care use (N=20,167) 100% 90% 100% 100% 80% 78% 60% 40% 20% 6% 10% 9% 44% 19% 22% 26% 38% Huisartscontacten GP contacts Polyfarmacie Polypharmacy Dagopname(s) Hospital day care Ziekenhuisopname(s) Hospital stay 0% Normal (57%) High (35%) Very high (8%) Hopman P, et al. Eur J Int Med 2016

31 Multimorbidity patients: subgroups according to health care use (N=20,167) Subgroup very high use (8%): 70% women Mean age 72 years Mean number of chronic diseases 3.1 More frequent: heart failure, COPD, ischaemic heart disease, diabetes mellitus Hopman P, et al. Eur J Int Med 2016

32 Diversity in multimorbid patients: not only in medical respect Morbidity profile Care needs (incl. social domain, e.g. loneliness ) Care complexity

33 Care programs for multimorbid patients in Europe (N=128) Noordman J, van der Heide I, Hopman P, Schellevis F, Rijken M. Innovative health care approaches for patients with multi-morbidity in Europe. Utrecht: NIVEL, February Bramwell C. Don RM,. Porter I, Lloyd H, Kadam U, Rijken M, Valderas JM. Caring for people with multiple chronic conditions in the United Kingdom: policy and practices with a focus on England and Scotland.

34 Examples of care programs for multimorbid patients POTKU, Finland Clinic for Multimorbidity and Polypharmacy, Denmark Strategy for Chronic Care Valencia Region, Spain Primary aim Target group Increase patientcenteredness Patients with chronic diseases Substitution of care, from secondary to primary care Patients with chronic diseases and complex care needs Improvement of integrated care High needs-/complex patients (top 5%) Setting Primary care Diagnostic center in hospital Primary and secondary care Care model Source: ICARE4EU Teams of GPs and nurses; individual care plan Teams of medical specialists; one-day service; treatment plan for GP Collaboration between casemanagers in primary and secondary care; joint monitoring Hopman P, et al. Eur J Int Med 2016

35 Typology of multimorbidity care programmes in Europe (N=128) Mainly bottom-up and temporary initiatives Much variation in models and work-up Common feature: important role of nurses Disease specific vs. integrated programs Integrated care programs more in countries with a strong primary care Source: ICARE4EU

36 Typology of multimorbidity care programmes in Europe (N=128) 42% focus on combinations of specific diseases ( index disease and common comorbidities): diabetes mellitus, ischaemic heart disease, heart failure, hypertension, kidney disease 58% integrated care programmes, personcentred care Source: ICARE4EU

37 Differences between disease-specific and general programmes Disease specific care Promoting evidence based practice Focus on prevention, diagnostics and treatment Source: ICARE4EU Integrated care Integration of different organizations (medical/social) Involving patients and informal carers Home care, nursing care, social care Case management

38 Systematic review of care programs

39 Systematic review of care programs 19 studies (only one in Europe) mainly focusing on frail elderly large variation in type of care program positive effects (+): patient satisfaction, quality of life, functioning no effects: health care utilisation, costs

40 European Multimorbidity care model Care process Decision support Self management support Information system Local support Periodic comprehensive patient evaluation Implementation evidence-based medicine Training care providers in tailored support Elektronic health records Access to local and community services Multidisciplinary team Team training Support patients in improving their health literacy Information exchange Involve local network and attention for physical environment Individual care plan Involve patients actively in decision making Uniform coding/ classification/langua ge Psychosocial support Casemanager Involve family members and care givers Patient portals Support patients in using ehealth applications Source: JA Chrodis

41 Management of multimorbid patients in consultations

42 Management of multimorbid patients

43 Management of multimorbid patients: the Ariadne principles

44 Polypharmacy Inevitable consequence of multimorbidity Usually defined as the simultaneous chronic use of five different medications Increased risks Non-adherence Interactions Adverse effects Hospitalisation, mortality

45 Polypharmacy: inter-practice variation Sinnige et al, 2016

46 Polypharmacy: multidisciplinary guideline Clinical medication review ( expert based ) Persons > 65 years of age using five different drugs Start and Stop criteria General practitioner + pharmacist Including patient information

47 Effectiveness of medication reviews: only on drug-related problems, not on clinical outcomes

48 Conclusions (1) Focus on patients with the highest needs: More research needed to identify multimorbid patients who will profit most Existing care programs Not embedded in national policies Very heterogeneous

49 Conclusions (2) Evidence of effective programs Mainly from US studies Investment in proper evaluations necessary Multimorbidity in consultations: experts say Individual care plans Systematic approach Polypharmacy: experts say Clinical medication reviews

50 Thank you for your attention!

Work package 6, task 2: Review existing care (pathway) approaches for multi-morbidity patients

Work package 6, task 2: Review existing care (pathway) approaches for multi-morbidity patients Work package 6, task 2: Review existing care (pathway) approaches for multi-morbidity patients Mieke Rijken Petra Hopman Janneke Noordman Franςois Schellevis Two activities:.. provide an overview of integrated

More information

Multimorbidity and systematic reviews

Multimorbidity and systematic reviews Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Multimorbidity and systematic reviews Susan Smith Department of General Practice, RCSI HRB Centre for Primary Care Research Inchicore

More information

Integrating Medical and Social Support for Elderly System & Technology Enabled Service Innovations. Dr Christina MAW Hospital Authority, Hong Kong

Integrating Medical and Social Support for Elderly System & Technology Enabled Service Innovations. Dr Christina MAW Hospital Authority, Hong Kong Integrating Medical and Social Support for Elderly System & Technology Enabled Service Innovations Dr Christina MAW Hospital Authority, Hong Kong Hospital Authority (HA) of Hong Kong A statutory body responsible

More information

Comorbidity patterns in cancer survivors in the 21st century. Marjan van den Akker

Comorbidity patterns in cancer survivors in the 21st century. Marjan van den Akker Comorbidity patterns in cancer survivors in the 21st century Marjan van den Akker Background Comorbidity & multimorbidity concepts relevance methodological challenges Comorbidity in cancer patients somatic

More information

Medication review in Parliament. HARM study (2006) Medication review in the Netherlands. HARM study Recommendations. HARM study Risk factors

Medication review in Parliament. HARM study (2006) Medication review in the Netherlands. HARM study Recommendations. HARM study Risk factors HARM study (2006) Medication review in the Netherlands An overview 2,4% of all admissions 34.000 hospital admissions 46% potentially avoidable 85 million euro Adrianne Faber Eindrapport HARM-onderzoek,

More information

Dr Conor Maguire Consultant, NHS Lothian Chair, Lothian Parkinson s Forum

Dr Conor Maguire Consultant, NHS Lothian Chair, Lothian Parkinson s Forum Dr Conor Maguire Consultant, NHS Lothian Chair, Lothian Parkinson s Forum I am a GERIATRICIAN Training: General Medicine Neurological conditions Cognition memory clinics Falls Multi-organ involvement of

More information

Urban Health Centres Europe (UHCE) Integrated social and health care to promote quality of life and independent living

Urban Health Centres Europe (UHCE) Integrated social and health care to promote quality of life and independent living E-mail: info@uhce.eu Website: http://uhce.eu/ Hein Raat, Carmen Franse, Elena Curtopassi Urban Health Centres Europe (UHCE) Integrated social and health care to promote quality of life and independent

More information

Changing care systems for people with frailty. John Young

Changing care systems for people with frailty. John Young Changing care systems for people with frailty John Young Geriatrician, Bradford Hospitals Trust, UK National Clinical Director for Integration & the Frail Elderly, NHS England (john.young@bthft.nhs.uk)

More information

Ageing Well. The challenge of our ageing population. Martin Vernon NCD Older People. Find Recognise Assess Intervene Long-term.

Ageing Well. The challenge of our ageing population. Martin Vernon NCD Older People. Find Recognise Assess Intervene Long-term. Ageing Well The challenge of our ageing population Martin Vernon NCD Older People 7 th June 2017 1 Projected UK age structure Foresight, 2016 2 Ageing impacts 15 million live with a long term condition

More information

NICE guideline Published: 21 September 2016 nice.org.uk/guidance/ng56

NICE guideline Published: 21 September 2016 nice.org.uk/guidance/ng56 Multimorbidity: clinical assessment and management NICE guideline Published: 21 September 2016 nice.org.uk/guidance/ng56 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).

More information

Young carers mental health

Young carers mental health Young carers mental health Francesca Centola Project Officer, Coordinator activities on and with young carers Sean Collins, Irish member of the Eurocarers Young Carers Working Group ENOC Annual Conference,

More information

Geriatric Medicine I) OBJECTIVES

Geriatric Medicine I) OBJECTIVES Geriatric Medicine I) OBJECTIVES 1 To provide a broad training and in-depth experience at a level sufficient for trainees to acquire competence and professionalism required of a specialist in Geriatric

More information

Case study: Individual with inadequate glycaemic control due to poor adherence to medication

Case study: Individual with inadequate glycaemic control due to poor adherence to medication Case study: Individual with inadequate glycaemic control due to poor adherence to medication Authored by Linong Ji and Clifford Bailey on behalf of the Global Partnership for Effective Diabetes Management.

More information

*GERIATRIC FELLOWSHIP COMPETENCY CHECKLIST EDUCATIONAL GOALS:

*GERIATRIC FELLOWSHIP COMPETENCY CHECKLIST EDUCATIONAL GOALS: *GERIATRIC FELLOWSHIP COMPETENCY CHECKLIST EDUCATIONAL GOALS: The goal of geriatric fellowship training is to prepare fellows for competency in the following core areas: Check and record date completed

More information

Living well with frailty. JOHN YOUNG National Clinical Director for the Frail Elderly & Integration, NHS England

Living well with frailty. JOHN YOUNG National Clinical Director for the Frail Elderly & Integration, NHS England Living well with frailty JOHN YOUNG National Clinical Director for the Frail Elderly & Integration, NHS England A LTC rarely travels alone Kent Whole Population Dataset: Interim Report 2014 The burden

More information

Optimal care for elderly in transition. Annemarie de Vos PhD MPH RN

Optimal care for elderly in transition. Annemarie de Vos PhD MPH RN Optimal care for elderly in transition Annemarie de Vos PhD MPH RN Introduction Geriatric care in the Netherlands under pressure 2030: 1.160.000 frail elderly Zeeland shows similar trends with regard to

More information

PHYSIOTHERAPY AND DIABETES

PHYSIOTHERAPY AND DIABETES PHYSIOTHERAPY AND DIABETES March 2006 Executive Summary The Australian Physiotherapy Association (APA) strongly supports the use of multidisciplinary teams to provide evidence-based care to individuals

More information

PSYCHOTROPIC SOLUTIONS

PSYCHOTROPIC SOLUTIONS PSYCHOTROPIC SOLUTIONS A proactive approach to antipsychotic medication management A Quality Use of Medicines initiative by Choice Aged Care Copyright 2018 Key Senate Committee Recommendations: All RACF

More information

Defining the patient population: one of the problems for palliative care research

Defining the patient population: one of the problems for palliative care research Postprint 1.0 Version Journal website http://pmj.sagepub.com/cgi/content/abstract/20/2/63 Pubmed link http://www.ncbi.nlm.nih.gov/pubmed/16613401 DOI 10.1191/0269216306pm1112oa Defining the patient population:

More information

Selecting the right patient for medication reviews

Selecting the right patient for medication reviews Selecting the right patient for medication reviews Prof dr Petra Denig, Clinical Pharmacy & Pharmacology, University Medical Center Groningen, the Netherlands 2 Who is in need of medication review: can

More information

Mental health and older people

Mental health and older people Mental health and older people Older people in Suffolk Older people are at risk of the same emotional and mental health difficulties as younger people. The majority of mental illness experienced by older

More information

INTERDEM MEMBERS BRIEF CURRICULUM VITAE

INTERDEM MEMBERS BRIEF CURRICULUM VITAE INTERDEM MEMBERS BRIEF CURRICULUM VITAE NAME: Marieke Perry TITLE: TITLE: MD, PhD PROFESSIONAL GROUPING: PROFESSIONAL GROUPING: General Practitioner WORK ADDRESS: WORK ADDRESS: 925 Geriatric Medicine TEL:

More information

Palliative Care Asking the questions that matter to me

Palliative Care Asking the questions that matter to me Palliative Care Asking the questions that matter to me THE PALLIATIVE HUB Adult This booklet has been developed by the Palliative Care Senior Nurses Network and adapted with permission from Palliative

More information

the high CVD risk smoker

the high CVD risk smoker Smoking Cessation: population and patients A comprehensive approach to the smoker the high CVD risk smoker Catriona Jennings Cardiovascular Specialist Research Nurse Imperial College London European Society

More information

Multimorbidity Is it really something new?

Multimorbidity Is it really something new? Multimorbidity Is it really something new? Dr Rokas Navickas Consultant cardiologist Vilnius University Hospital Santariskiu Clinic Multimorbidity WP co-leader, CHRODIS Joint Action Programme European

More information

EUROHOPE: Hip fracture in Europe are slippery regions different?

EUROHOPE: Hip fracture in Europe are slippery regions different? EUROHOPE: Hip fracture in Europe are slippery regions different? 25 Sep, 2012 Emma Medin Karolinska Institutet, Stockholm, Sweden Hip fracture is the most common fracture and associated with increased

More information

Coronary Heart Disease and Stroke, Primary and Secondary Prevention Guidelines (Cholesterol)

Coronary Heart Disease and Stroke, Primary and Secondary Prevention Guidelines (Cholesterol) CLINICAL GUIDELINE Coronary Heart Disease and Stroke, Primary and Secondary Prevention Guidelines (Cholesterol) A guideline is intended to assist healthcare professionals in the choice of disease-specific

More information

Ways to Wellbeing. Social Prescribing Programme. Social Impact Report Report produced by:

Ways to Wellbeing. Social Prescribing Programme. Social Impact Report Report produced by: Ways to Wellbeing Social Prescribing Programme Social Impact Report 2016-2017 Report produced by: Who We Are Wellbeing Enterprises CIC is an award winning social enterprise recognised for its innovative

More information

Chronic Conditions The need for a comprehensive public health approach

Chronic Conditions The need for a comprehensive public health approach Chronic Conditions The need for a comprehensive public health approach Olga McDaid PhD Scholar HRB PhD Programme for Health Services Research, Trinity College Dublin Supervisors Prof. Charles Normand,

More information

Results of the liberalisation of Medisave for a population-based diabetes management programme in Singapore

Results of the liberalisation of Medisave for a population-based diabetes management programme in Singapore Results of the liberalisation of Medisave for a population-based diabetes management programme in Singapore Woan Shin TAN 1, Yew Yoong DING 1, 2, Christine WU 3, Bee Hoon HENG 1 1 Health Services and Outcomes

More information

Brazil Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018

Brazil Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018 Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen,, October 2018 LEO Innovation Lab in cooperation with The Happiness Research Institute, 2018. All rights reserved. Any part of

More information

Coordination of palliative care in community settings. Summary report

Coordination of palliative care in community settings. Summary report Coordination of palliative care in community settings Summary report This resource may also be made available on request in the following formats: 0131 314 5300 nhs.healthscotland-alternativeformats@nhs.net

More information

Supplemental materials for:

Supplemental materials for: Supplemental materials for: Wallis KA, Andrews A, Henderson M. Swimming against the tide: primary care physicians views on deprescribing in everyday practice. Ann Fam Med. 2017;15(4):341-346. General Practice

More information

Jennifer Loh, MD, FACE Chief of Endocrinology KP Hawaii AAMD of Medical Education, KP Hawaii

Jennifer Loh, MD, FACE Chief of Endocrinology KP Hawaii AAMD of Medical Education, KP Hawaii Individualized Diabetes Treatment for the Elderly Jennifer Loh, MD, FACE Chief of Endocrinology KP Hawaii AAMD of Medical Education, KP Hawaii Extremely Relevant Baby Boomers are aging! ¼ of people age

More information

Ageing Well. Frailty: why is it important? Martin Vernon NCD Older People. Find Recognise Assess Intervene Long-term.

Ageing Well. Frailty: why is it important? Martin Vernon NCD Older People. Find Recognise Assess Intervene Long-term. Ageing Well Frailty: why is it important? Martin Vernon NCD Older People 22 th March 2017 1 Its not how old we are, but how we are old 2 UK Ageing Population Source: Office for National Statistics, National

More information

Outcome Statement: National Stakeholders Meeting on Quality Use of Medicines to Optimise Ageing in Older Australians

Outcome Statement: National Stakeholders Meeting on Quality Use of Medicines to Optimise Ageing in Older Australians Outcome Statement: National Stakeholders Meeting on Quality Use of Medicines to Optimise Ageing in Older Australians Executive summary Australia has a significant opportunity to improve the quality use

More information

Fatigue after stroke. What is post-stroke fatigue? Who is affected by post-stroke fatigue?

Fatigue after stroke. What is post-stroke fatigue? Who is affected by post-stroke fatigue? Call the Stroke Helpline: 0303 3033 100 or email: info@stroke.org.uk Fatigue after stroke Fatigue affects half of all stroke survivors, but the signs of fatigue are not always obvious to other people and

More information

Denmark Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018

Denmark Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018 Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen,, October 2018 LEO Innovation Lab in cooperation with The Happiness Research Institute, 2018. All rights reserved. Any part of

More information

NICE Chronic Heart Failure Guidelines in Adults 2018

NICE Chronic Heart Failure Guidelines in Adults 2018 NICE Chronic Heart Failure Guidelines in Adults 2018 The Whys, Whats and Hows of the importance of effectively managing heart failure in Primary Care and the community. Foreword Dr Clare J Taylor, General

More information

Audit support for continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (review of technology appraisal guidance 57)

Audit support for continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (review of technology appraisal guidance 57) Audit support for continuous subcutaneous insulin (review of technology appraisal guidance 57) Issue date: 2008 Audit support Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus

More information

The Role of Family Medicine in Chronic Disease Management: the rising importance to healthcare

The Role of Family Medicine in Chronic Disease Management: the rising importance to healthcare The Role of Family Medicine in Chronic Disease Management: the rising importance to healthcare Dr Jun LIANG Chief of Service Department of Family Medicine & Primary Health Care New Territories West Cluster

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Chronic kidney disease: early identification and management of adults with chronic kidney disease in primary and secondary

More information

Toward a Comprehensive Diabetes Care Model for Older People

Toward a Comprehensive Diabetes Care Model for Older People Toward a Comprehensive Diabetes Care Model for Older People Professor L. Rodriguez Mañas Hospital Universitario de Getafe Madrid, Spain Professor Alan J Sinclair Professor of Medicine and Consultant Diabetologist

More information

Frailty and relationship centred care in dementia

Frailty and relationship centred care in dementia Frailty and relationship centred care in dementia Dr Karen Harrison Dening Head of Research & Publications Dementia UK I will consider Frailty, Comorbidity, Multi morbidity & Dementia Older, spousal carers

More information

The Community Assessment of Risk and Treatment Strategies (CARTS) Project. Professor D. William Molloy COLLAGE University College Cork, Ireland.

The Community Assessment of Risk and Treatment Strategies (CARTS) Project. Professor D. William Molloy COLLAGE University College Cork, Ireland. The Community Assessment of Risk and Treatment Strategies (CARTS) Project Professor D. William Molloy COLLAGE University College Cork, Ireland. Centre for Gerontology and Rehabilitation A time of limited

More information

Heart Failure. A Marvellous Story with More to Come. Prof Ken McDonald National Clinical Lead for Heart Failure

Heart Failure. A Marvellous Story with More to Come. Prof Ken McDonald National Clinical Lead for Heart Failure Heart Failure A Marvellous Story with More to Come Prof Ken McDonald National Clinical Lead for Heart Failure Advances in Heart Failure over Last 20 years Pharmacotherapy in HF-REF ADHF 50-15% Community

More information

From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home

From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home Muntinga et al. BMC Health Services Research (2015) 15:18 DOI 10.1186/s12913-014-0662-6 RESEARCH ARTICLE Open Access From concept to content: assessing the implementation fidelity of a chronic care model

More information

ACTION GROUP A1 PRESCRIPTION AND ADHERENCE TO TREATMENT

ACTION GROUP A1 PRESCRIPTION AND ADHERENCE TO TREATMENT ACTION GROUP A1 PRESCRIPTION AND ADHERENCE TO TREATMENT COMMITMENTS OF THE BASQUE COUNTRY 1 JUNE 2013 OUTLINE OBJECTIVES COMMITMENTS INSTRUMENTAL PROJECTS DELIVERABLES: OBJECTIVE 2. Empower the patients

More information

Influencing planning to improve the quality of Parkinson s care in Scotland

Influencing planning to improve the quality of Parkinson s care in Scotland Influencing planning to improve the quality of Parkinson s care in Scotland This short guide enables you to influence commissioning by making the case for high quality, cost-effective care for people affected

More information

Table Of Content. Appropriate care paths for frail elderly patients: a comprehensive model... 2 Summary... 3 Work Package... 7

Table Of Content. Appropriate care paths for frail elderly patients: a comprehensive model... 2 Summary... 3 Work Package... 7 Table Of Content Appropriate care paths for frail elderly patients: a comprehensive model... 2 Summary... 3 Work Package... 7 Coordination of the project... 7 Dissemination of the project... 7 Evaluation

More information

Information for patients, service users, families and carers. Eating disorder service. Kent and Medway.

Information for patients, service users, families and carers. Eating disorder service. Kent and Medway. EATING DISORDER SERVICE KENT& MEDWAY Information for patients, service users, families and carers Eating disorder service Kent and Medway www.nelft.nhs.uk EATING DISORDER SERVICE KENT& MEDWAY 2 NELFT Eating

More information

Patient Education, Diabetes Education, Structured Patient Education What does it all really mean to a person with Diabetes?

Patient Education, Diabetes Education, Structured Patient Education What does it all really mean to a person with Diabetes? Patient Education, Diabetes Education, Structured Patient Education What does it all really mean to a person with Diabetes? Linda Burns Community Diabetes Nurse Specialist Glasgow North West Diabetes MCN

More information

Presentation of a specific research project

Presentation of a specific research project Presentation of a specific research project Appropriate use of medicines in care of the elderly: Factors underlying inappropriateness, and impact of the clinical pharmacist Anne Spinewine 04.10.2011 WBI-

More information

EIP AHA Valencia 2016 Towards an Active and Healthy Ageing. Emilia-Romagna Region - Reference Site EIP-AHA

EIP AHA Valencia 2016 Towards an Active and Healthy Ageing. Emilia-Romagna Region - Reference Site EIP-AHA EIP AHA Valencia 2016 Towards an Active and Healthy Ageing Emilia-Romagna Region - Reference Site EIP-AHA A Regional Model to Predict Identify and Manage Multimorbidity and Frailty Mirca Barbolini Valencia

More information

The Chinese University of Hong Kong The Nethersole School of Nursing. CADENZA Training Programme

The Chinese University of Hong Kong The Nethersole School of Nursing. CADENZA Training Programme The Chinese University of Hong Kong The Nethersole School of Nursing CTP003 Chronic Disease Management and End-of-life Care Web-based Course for Professional Social and Health Care Workers Copyright 2012

More information

Caroline S. Blaum, MD, MS Diane and Arthur Belfer Professor of Geriatrics Director, Division of Geriatric Medicine New York University Langone

Caroline S. Blaum, MD, MS Diane and Arthur Belfer Professor of Geriatrics Director, Division of Geriatric Medicine New York University Langone Caroline S. Blaum, MD, MS Diane and Arthur Belfer Professor of Geriatrics Director, Division of Geriatric Medicine New York University Langone Medical Center About the AGS Mission To improve the health,

More information

Blood Pressure Acre Surgery Diviash Thakrar

Blood Pressure Acre Surgery Diviash Thakrar Blood Pressure Acre Surgery Diviash Thakrar Why Are We Doing This? 1. Improve education for patients within the practice 2. Allow us use this for general health promotion Raise money for charity 3. Raise

More information

Location of initiative York Region Chronic Kidney Disease Program, Mackenzie Richmond Hill Hospital, Richmond Hill, ON

Location of initiative York Region Chronic Kidney Disease Program, Mackenzie Richmond Hill Hospital, Richmond Hill, ON Story #1 CSHP 2015 objective Objective 2.1 - In 70% of ambulatory and specialized care clinics providing clinic care, pharmacists will manage medication therapy for clinic patients with complex and high-risk

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE QUALITY AND OUTCOMES FRAMEWORK (QOF) INDICATOR DEVELOPMENT PROGRAMME Briefing paper QOF indicator area: Peripheral arterial disease Potential output:

More information

Division of Medicine. Department of Geriatric Medicine. Staff. Jerry Ciocon, M.D., F.A.C.P., F.A.C.A., A.G.S.F. Diana J. Galindo, M.D.

Division of Medicine. Department of Geriatric Medicine. Staff. Jerry Ciocon, M.D., F.A.C.P., F.A.C.A., A.G.S.F. Diana J. Galindo, M.D. Division of Medicine Department of Geriatric Medicine Staff Jerry Ciocon, M.D., F.A.C.P., F.A.C.A., A.G.S.F. Diana J. Galindo, M.D. 1 Chairman s Letter We are all getting older, and providing the care

More information

SMR Palliative Care Forum The Intersection: Chronic disease and Palliative Care. Chronic Heart Failure

SMR Palliative Care Forum The Intersection: Chronic disease and Palliative Care. Chronic Heart Failure SMR Palliative Care Forum The Intersection: Chronic disease and Palliative Care. Chronic Heart Failure Bruce Jackson Physician (General Medicine, Nephrology, Cardiology) Inpatient ward service in General

More information

Older People with Complex Health Needs: NIHR Workshop Delegate Agenda The Royal Society 6-9 Carlton House Terrace London SW1Y 5AG

Older People with Complex Health Needs: NIHR Workshop Delegate Agenda The Royal Society 6-9 Carlton House Terrace London SW1Y 5AG Older People with Complex Health Needs: NIHR Workshop Delegate Agenda The Royal Society 6-9 Carlton House Terrace London SW1Y 5AG Wednesday 2 nd November 2016 A workshop to identify tractable research

More information

2. Quality and Outcomes Framework: new NICE recommendations

2. Quality and Outcomes Framework: new NICE recommendations Proposed Changes to the GMS Contract 2013/14 1. GP pay and expenses uplift It is proposed GP pay and expenses is uplifted by 1.5%. This increased investment will allow for an average pay increase of up

More information

Population Health Analytics and Usage of the ACG System in the UK Stockholm, 13 th June, 2017 Alan Thompson, Director of User Support

Population Health Analytics and Usage of the ACG System in the UK Stockholm, 13 th June, 2017 Alan Thompson, Director of User Support Population Health Analytics and Usage of the ACG System in the UK Stockholm, 13 th June, 2017 Alan Thompson, Director of User Support athompson@hopkinsacg.org Content Summary of main uses of the ACG System

More information

United Kingdom Editors:

United Kingdom Editors: Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen,, October 2018 LEO Innovation Lab in cooperation with The Happiness Research Institute, 2018. All rights reserved. Any part of

More information

Aldo P. Maggioni, Kees Van Gool, Nelly Biondi, Renato Urso, Niek Klazinga, Roberto Ferrari, Nikolaos Maniadakis and Luigi Tavazzi.

Aldo P. Maggioni, Kees Van Gool, Nelly Biondi, Renato Urso, Niek Klazinga, Roberto Ferrari, Nikolaos Maniadakis and Luigi Tavazzi. Appropriateness of prescriptions of recommended treatments in OECD health systems: findings based on the Long-Term Registry of the ESC on Heart Failure Aldo P. Maggioni, Kees Van Gool, Nelly Biondi, Renato

More information

Clinical Care Team approach to management of key conditions

Clinical Care Team approach to management of key conditions Clinical Care Team approach to management of key conditions BJD Ho Chi Minh City Nov 30, 2012 Kristina Åkesson, MD, PhD Dept of Orthopedics Malmö University Hospital Lund University Malmö, Sweden Multidisciplinary

More information

Special thanks to the EJC Foundation for their support of Sanford Center Geriatric Specialty Clinic

Special thanks to the EJC Foundation for their support of Sanford Center Geriatric Specialty Clinic Special thanks to the EJC Foundation for their support of Sanford Center Geriatric Specialty Clinic Sanford Center for Aging 775-784-4744 med.unr.edu/aging Diabetes Management Series: From Selfmanagement

More information

Pain Management in the Elderly. Dr Cathy Price

Pain Management in the Elderly. Dr Cathy Price Pain Management in the Elderly Dr Cathy Price Outline Typical cases Background knowledge Pain assessment Treatment options - evidence base Systems needed Applying the evidence base to cases Case 1- Pain

More information

Welcome to the Routine frailty identification in the GP contract webinar presented by Dawn Moody

Welcome to the Routine frailty identification in the GP contract webinar presented by Dawn Moody Welcome to the Routine frailty identification in the GP contract webinar presented by Dawn Moody The presentation will begin at 12.00pm. Attendees will be muted during the presentation to avoid interference.

More information

Realising the potential of AHPs to support those with cancer in the future

Realising the potential of AHPs to support those with cancer in the future Realising the potential of AHPs to support those with cancer in the future June Davis National cancer rehabilitation lead Macmillan Cancer Support 1 st June 2016 The shifting pattern of survival Total

More information

The COLLaboration on AGEing (COLLAGE)

The COLLaboration on AGEing (COLLAGE) The COLLaboration on AGEing (COLLAGE) Professor D. William Molloy University College Cork, Ireland. The Lessons from Europe Seminar 23-09-15 Overview Exemplars within COLLAGE: 1. What is COLLAGE? 2. The

More information

Making Healthy Normal

Making Healthy Normal Making Healthy Normal Learning from Australia s Aged Care system Still gaps in embedded - focus and access to health promoting activities - early intervention programs - critical thinking/case management

More information

New evidence for the positive relationship between sports, health and ageing

New evidence for the positive relationship between sports, health and ageing 1 10 januari 2011 New evidence for the positive relationship between sports, health and ageing Prof.dr. Marijke Hopman-Rock dr. Nico van Meeteren TNO, Leiden and BodyatWork research center TNO - VU university

More information

Integration; Frailty; and efi

Integration; Frailty; and efi Integration; Frailty; and efi John Young Geriatrician, Bradford Hospitals Trust, UK National Clinical Director for Integration & the Frail Elderly, NHS England (john.young@bthft.nhs.uk) NHS England Older

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE. Type 2 diabetes: the management of type 2 diabetes (update)

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE. Type 2 diabetes: the management of type 2 diabetes (update) NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Type 2 diabetes: the management of type 2 diabetes (update) 1.1 Short title Type 2 diabetes (update) 2 Background a) The National

More information

PSYCHOTROPIC SOLUTIONS

PSYCHOTROPIC SOLUTIONS PSYCHOTROPIC SOLUTIONS A proactive approach to antipsychotic medication management A Quality Use of Medicines initiative by Choice Aged Care Copyright 2018 Hello everyone. Today we will be discussing the

More information

A logical approach to planning health care services in relation to need Dr Christopher A Birt University of Liverpool

A logical approach to planning health care services in relation to need Dr Christopher A Birt University of Liverpool EUREGIO III A logical approach to planning health care services in relation to need Dr Christopher A Birt University of Liverpool PURPOSE OF A HEALTH SERVICE To utilise resources allocated to the health

More information

Integrated Care Models That Work for Frail Older People

Integrated Care Models That Work for Frail Older People Integrated Care Models That Work for Frail Older People The King's Fund Integrated Care: Key Factors for Success Conference London, 18 September 2012 Dennis L. Kodner, PhD, FGSA, International Visiting

More information

Spain Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018

Spain Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018 Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen,, October 2018 LEO Innovation Lab in cooperation with The Happiness Research Institute, 2018. All rights reserved. Any part of

More information

Proof of Concept: NHS Wales Atlas of Variation for Cardiovascular Disease. Produced on behalf of NHS Wales and Welsh Government

Proof of Concept: NHS Wales Atlas of Variation for Cardiovascular Disease. Produced on behalf of NHS Wales and Welsh Government Proof of Concept: NHS Wales Atlas of Variation for Cardiovascular Disease Produced on behalf of NHS Wales and Welsh Government April 2018 Table of Contents Introduction... 3 Variation in health services...

More information

United States Editors:

United States Editors: Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen,, October 2018 LEO Innovation Lab in cooperation with The Happiness Research Institute, 2018. All rights reserved. Any part of

More information

Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION

Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION Dr Kornelia Kotseva National Heart & Lung Insitute Imperial College London, UK on behalf of all investigators participating

More information

Working Paper Distribution and types of multiple chronic conditions in Korea. Young-Ho Jung, Sukja Ko

Working Paper Distribution and types of multiple chronic conditions in Korea. Young-Ho Jung, Sukja Ko Working Paper 2014-09 Distribution and types of multiple chronic conditions in Korea Young-Ho Jung, Sukja Ko Distribution and types of multiple chronic conditions in Korea Young-Ho Jung, Research Fellow

More information

PATIENT & CIVIL SOCIETY REPRESENTATIVES ROUNDTABLE INCONTINENCE AND THE PROVISION OF BETTER CONTINENCE CARE AT HOME AND IN THE COMMUNITY

PATIENT & CIVIL SOCIETY REPRESENTATIVES ROUNDTABLE INCONTINENCE AND THE PROVISION OF BETTER CONTINENCE CARE AT HOME AND IN THE COMMUNITY PATIENT & CIVIL SOCIETY REPRESENTATIVES ROUNDTABLE INCONTINENCE AND THE PROVISION OF BETTER CONTINENCE CARE AT HOME AND IN THE COMMUNITY JOINT POSITION STATEMENT On 1 July 2015, representatives of pan-european

More information

What is the clinical problem?

What is the clinical problem? Team T2D: Empowering people living with Type 2 Diabetes Implementation and Evaluation of the Combined RBWH and QUT Health Clinics Model of Care for Patients with Type 2 Diabetes Adrienne Young: Research

More information

Reshaping Care Pathways for Older People. Anne Hendry National Clinical Lead for Quality

Reshaping Care Pathways for Older People. Anne Hendry National Clinical Lead for Quality Reshaping Care Pathways for Older People Anne Hendry National Clinical Lead for Quality Reshaping Care for Older People 10 Year Programme to 2021 300 million Change Fund to 2015 32 Partnerships between

More information

Challenges in managing multiple conditions: The patient experience of multimorbidity

Challenges in managing multiple conditions: The patient experience of multimorbidity original article Challenges in managing multiple conditions: The patient experience of multimorbidity Jenny Comorbidity, multimorbidity, National University of polypathology Ireland, Galway a range of

More information

SURVEY ON THE EXPERIENCE AND NEEDS OF PATIENTS

SURVEY ON THE EXPERIENCE AND NEEDS OF PATIENTS SURVEY ON THE EXPERIENCE AND NEEDS OF PATIENTS LIVING WITH OESOPHAGEAL OR GASTRIC CANCER I am writing to you on behalf of EuropaColon, a not-for-profit organization established in 00, dedicated to saving

More information

Potential Vision for Diabetes Care

Potential Vision for Diabetes Care Potential Vision for Diabetes Care Stirling Court Hotel, Stirling 2 nd February 2018 Brian Kennon, Consultant Diabetologist, Queen Elizabeth University Hospital, Glasgow #improvediabetes2018 Outline What

More information

Portugal Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018

Portugal Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen, Denmark, October 2018 Editors: LEO Innovation Lab and The Happiness Research Institute Copenhagen,, October 2018 LEO Innovation Lab in cooperation with The Happiness Research Institute, 2018. All rights reserved. Any part of

More information

Identificación de factores claves en la gestión de casos para pacientes crónicos en situación de complejidad Claire Goodman Professor of Health Care

Identificación de factores claves en la gestión de casos para pacientes crónicos en situación de complejidad Claire Goodman Professor of Health Care Identificación de factores claves en la gestión de casos para pacientes crónicos en situación de complejidad Claire Goodman Professor of Health Care Research Centre for Research in Primary and Community

More information

To Take or Not To Take?

To Take or Not To Take? To Take or Not To Take? Assessment Question How do the terms adherence & compliance differ? 1. The terms are synonymous 2.Adherence assumes collaboration between patient & provider while compliance suggests

More information

The Complex Relationship Between Depression and Nutrition in the Elderly. A presentation for providers of long term and inhome

The Complex Relationship Between Depression and Nutrition in the Elderly. A presentation for providers of long term and inhome The Complex Relationship Between Depression and Nutrition in the Elderly A presentation for providers of long term and inhome care General Indicators of Health Status Nutritional Status! Dietary Intake!

More information

Living well today...32 Hope for tomorrow...32

Living well today...32 Hope for tomorrow...32 managing diabetes managing managing managing managing managing managing diabetes Scientific research continually increases our knowledge of diabetes and the tools to treat it. This chapter describes what

More information

MEDICINES ADHERENCE The Role of the Pharmacist

MEDICINES ADHERENCE The Role of the Pharmacist BROUGHT TO YOU BY MEDICINES ADHERENCE The Role of the Pharmacist Developed by Pfizer 15 May, 2017 This learning module is intended for UK healthcare professionals only. Job code; PP-GEP-GBR-0682. Date

More information

Understanding Parkinson s for health and social care staff. The phases of Parkinson s

Understanding Parkinson s for health and social care staff. The phases of Parkinson s Understanding for health and social care staff The phases of The phases of Diagnosis 11% 1.6 Post diagnosis before symptoms have become significant Maintenance 40.4% 5.9 Symptoms significant but largely

More information

2015 UK Parkinson s Audit Patient and carer report

2015 UK Parkinson s Audit Patient and carer report 2015 UK Parkinson s Audit Patient and carer report Introduction This is a summary of the main findings of the 2015 UK Parkinson s Audit. This is the fifth and largest audit of Parkinson s to date. This

More information

Ethical questions about biomarkers of ageing the view of geriatrics

Ethical questions about biomarkers of ageing the view of geriatrics Ethical questions about biomarkers of ageing the view of geriatrics Biomarker of Ageing Halle 18.-20.09.2009 Manfred Gogol, M.D. Coppenbrügge Definition Biomarker of Ageing (BMA) are agents that allows

More information

Sept Oct Nov Your life, your choice, your health! h e a l t hy C A M R O S E L I V I N G C E N T R E

Sept Oct Nov Your life, your choice, your health! h e a l t hy C A M R O S E L I V I N G C E N T R E Sept Oct Nov 2016 Your life, your choice, your health! C A M R O S E h e a l t hy L I V I N G C E N T R E INDEX OF CLASSES OFFERED NAME OF CLASS PAGE NAME OF CLASS PAGE Chronic Disease Management NUMBER

More information