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IDEAS FOR IMPLEMENTATION AT CMC, VELLORE

FOLLOWING THE VISIT TO

MAYO CLINIC, ROCHESTER Vinod Joseph Abraham Professor, Dept. of Community Health Christian Medical College, Vellore India

VISION STATEMENT - CMC The Christian Medical College, Vellore, seeks to be a witness to the healing ministry of Christ, through excellence in education, service and research MISSION STATEMENT - MAYO To inspire hope and contribute to health and wellbeing by providing the best care to every patient through integrated clinical practice, education and research

Christian Medical College & Hospital

Founded by Ida Sophia Scudder Started as a 1 bed clinic in 1900 School for women nurses in 1909 Training for women doctors in 1918 Currently Over 2000 inpatient beds Over 7500 outpatients per day Over 8000 staff

Community Health Department Provides primary and secondary care to: Rural population (Kaniyambadi Block) Tribal area (Jawadhi Hills) Urban area- poorer sections of Vellore Town

KANIYAMBADI BLOCK • Predominantly Rural

• Total population ~116,000 • Number of villages ~ 80

• Occupation was predominantly agricultural • More & more of the younger generation are moving into urban areas for residence and for work

Structure of the Health Team Kaniyambadi Block Doctors

Public Health Nurses

Health Aides

Population 35000

Population 20000

Population 7000

Visit 1/month

Visit 3/month

Visit Every week

PTCHW 1 per village

Reside in the village

Information System Managers

Data is entered, stored and analysed Doctors (Residents)

Health Aide

Statistician Public Health Nurse

PTCHW

Components of the Information System

• Maternal Health – Antenatal period, Risk Factors, Delivery, Post-natal period, Outcomes • Child Health – Birth weight, Immunization, mortality • Infectious diseases – all ages • Deaths – Verbal autopsy

• Specific programs – TB, Leprosy, Tribal

How is care provided in Kaniyambadi Block

Socio Economic Development

Involvement & Education in the Community

More recent areas of focus of the Department

• Care for the elderly in the community • NCD screening prevention • Cancer screening

Health problems of the elderly. 50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

Multicentre study to establish epidemiological data on elderly: WHO,GOI 2007

Social Problems

- Participation in social events - Loneliness - Dependency - activities of daily living ( ADL) - Quality of life - Neglect -

Abuse Personal hygiene Sexual adjustment Emotional disorders

Economic • No earnings • Dependancy • Inability to afford comprehensive medical treatment 90 % of old persons in India are from the unorganized sector – no regular source of income (large industrial work force, contract labour, agricultural labour, daily wage labour)

Care for the Elderly

Visit to Mayo Clinic, Rochester How can we adapt ideas and strategies from Mayo Clinic to improve care for the elderly in CMC, Vellore

Programs Observed / Visited at Mayo

• Care Transitions Program – RNs and home visits with NPs • Adult Care Coordination Program • Homestead Facility • Geriatric Home visits • Palliative Care Homebound Program • Seasons Hospice • Mayo Hospice • Geriatric Core Meeting • Amalga Migration Meetings

Meetings / Discussions held with the following Staff Dr. Rajeev Chaudhry

Mr. Praveen Ramu

CTP/PCP

Dr. Gregory J. Hanson

Mr. Alex K. Alexander

Ms. Tanya L. Peda

Dr. Paul Y. Takahashi

Mr. Parvez A. Rahman

Ms. Deanne W. Wallenstein

Dr. Anupam Chandra

Ms. Diane Lentz

Ms. Lynn Borkenhagen

Dr. Frank (Andy) A. Bock

Mayo Hospice

Seasons Hospice

Dr. Bjoerg Thorsteinsdottir

Ms. Rachel Fratzke

Dr. Mesick

Dr. Mairead Bartley

Ms. Maureen Bigelow

Ms. Kathy

Dr. Elise Carey

Mr. Brent Moos

Dr. Nathan K. LeBrasseur

Strengths of the existing system in the Community Health Dept., CMC, Vellore  Multidisciplinary team: Doctors – Community Medicine, Family medicine, Paediatrics, Obstetrics and Internal Medicine Doctors – Residents & Interns Nurses Occupational Therapist Social workers Health Educator  Well-developed information system  Existing infrastructure for provision of primary and secondary health care  Close link between primary - secondary - tertiary levels of health care  Strong mission, vision and value system in the institution

Opportunities at CMC  Use the information system to track & manage chronic diseases

 More effective use of Team members  Set up Programs in the community o Care of frail and bedridden elderly o Home based Palliative care o Home based Hospice care

 Better use of technology

 Screening for Important conditions – Risk of Falls, Dementia

Proposed Interventions  Chronic Disease Management

 Community Based Care for Frail/Homebound elderly  Home based Palliative and Hospice care

 Preventing readmissions among retired staff/dependants (> 60 years)

 Screening elderly in the outpatient for risk of falls

 Screen for dementia in the outpatient & community

CHRONIC DISEASE MANAGEMENT IN THE COMMUNITY WEAKNESSES WITH THE CURRENT SYSTEM 1. Different doctor sees the patient at each visit

2. Protocol for management not as good as it should be

3. Patient makes 2-3 visits to hospital in order to have and review an investigation

4. Documentation of physician reviews and link with hospital records inadequate 5. Frail and bedridden patients not monitored for chronic diseases 6. Family not adequately involved in care of patients 7. Not being monitored for polypharmacy

8. Inadequate involvement of the entire health care team in management

Strategy Chronic Disease Management

• •

Set up registries for specific chronic diseases in the community (from

existing database, passive and active screening)

Create a database/tracking system which will provide information for

required outcome indicators and for established treatment protocols

•

Draw up specific roles and responsibilities for each member of the team

•

Conduct training for the different team members

•

Each patient contacted at home / clinic / hospital and included into the

•

program

Initiate home visits & telephonic support

• Monitor and Evaluate the program

Areas of Focus Chronic Disease Management

- Plan and track the management plan for each patient - Incorporate protocols for each disease (with alerts) ďƒ Improve quality of care

- Better utilization of manpower in the community

(Doctors, Nurse, OT, Social Worker â€“ specific responsibilities for each member)

- Introduce telephonic support in management of the same diseases - Reduce unnecessary patient visits to the clinic

- Address the issue of management of chronic diseases among frail/bedridden patients

Conditions to be Included in the Registry

• Chronic diseases – DM, HT, Asthma, COPD, RHD, RF, RA, CAD, Seizure,

• Mental Illnesses – Schizophrenia, Depression, Bipolar, etc. • Disabilities - Stroke, Paralysis, Osteoarthritis • Cancers • Infectious Diseases – TB, HIV • High risk under 5 children

Care For Elderly â€“ Particularly Frail / Homebound Elderly Use a model similar to the one for chronic diseases

HOME BASED PALLIATIVE & HOSPICE CARE

Objective

â€˘ To provide comprehensive care for patients

and families dealing with chronic, life limiting disease.

(The focus of palliative care is on control of

symptoms, management of complications, and quality of life)

Team Members • Physicians Faculty-(Community Medicine, Family

Medicine, Palliative Care, Primary Physicians of any specialty); Residents, Interns

• Nurses - BSc Trained nurses, Diploma Trained Nurses • Health Aides

• Occupational Therapist • Social Workers • Counsellors • Chaplains

Work Flow •

Referral to Palliative/Hospice Care by patient / •

Encourage volunteers in the village

•

Confirm eligibility (at least 2 doctors)

RN/Doctor

• •

family / treating physician

Counseling/Introduction session with patient & relatives

Documentation and signatures

• Regular phone calls (?weekly) by • Review symptoms

• Medicine reconciliation

Detailed work up by Doctor, Nurse & Social

• Plan online prescriptions

•

Provide basic medicines based on standing

• Assistance in home modifications and

•

Home visit by the Doctor/Nurse

•

worker orders

Schedule home visits by RN/OT/SW/HA

• Diet education

provision of aids

• Support towards end of life

REDUCING HOSPITAL STAY & OUTPATIENT VISITS FOR RETIRED STAFF & DEPENDANTS

Reducing Length of Unnecessary Hospital Inpatient Stay & Readmissions

o Notification when such patients are admitted

o Network with the admitting physician during the hospital stay o Contact with the patient and family prior to discharge

o Home visit by the team (? Nurse) following discharge from hospital

o Care provided at home in consultation with the admitting physician

Avoid Unnecessary Outpatient Visits

o Establish a data base of frail retired staff & dependants

o Develop an individualized treatment plan for each patient in consultation with the primary treating physician and the geriatrics unit o Organize home visits by doctors & nurses

Focus during Home Visits • Early Recognition and Management of Acute Issues • Measurement of vitals

• Examine skin for bed sores among bedridden patients • Medication Reconciliation

• Home Safety Assessment • Advanced Care Planning • Referrals as necessary

• Plan for diet and activities

• Simplify process for investigations as needed

• SCREEN FOR DEMENTIA IN THE OUTPATIENT & COMMUNITY • SCREEN FOR ‘AT RISK FOR FALLS’ IN THE ELDERLY

Thank You for your time and inputâ€¦.. Dr. Rajeev Chaudhry