Merwan Saher, Auditor General of Alberta, released his office’s audit into how the Department of Health and Alberta Health Services manage healthcare delivery for individuals with chronic disease—a long-lasting condition that usually becomes worse and often cannot be cured.
The purpose of chronic disease management is to provide care that helps people with chronic disease improve their quality of life and live as long as possible. Effective chronic disease management can also reduce overall costs to the public healthcare system. The most common chronic diseases in Alberta include hypertension (high blood pressure), diabetes, chronic obstructive pulmonary disease, asthma, heart failure, coronary artery disease, obesity and depression. The personal consequences of these diseases can range from pain, impaired mobility, reduced ability to work, and social isolation to dependence on drugs, repeated trips to hospital, amputations and early death.
The financial costs to Alberta’s healthcare system run into billions of dollars. Chronic diseases require the services of thousands of healthcare professionals and the infrastructure and systems to support them. People with chronic diseases account for nearly two-thirds of hospital inpatient days, one-third of all visits to physicians and more than one-quarter of visits to emergency rooms.
Why chronic disease management is important to Albertans
Chronic diseases are arguably the largest challenge facing our healthcare system. More than any other health problem, chronic diseases shorten people’s lives and make their lives more difficult.
Chronic diseases are also the largest drivers of healthcare costs—they are the most common cause of hospitalizations and emergency department visits, and the most common reason for family physician visits. The burden of chronic disease will increase as our population grows and ages, and unhealthy lifestyle factors lead to higher rates of new cases of chronic disease. Effective management of chronic diseases is therefore critical to the health of Albertans and the long-term sustainability of our public healthcare system.
What we found
We were consistently impressed with the skills, resourcefulness and dedication of the people we met in all the entities we contacted. We noted many good practices, several of which we refer to in this report because we believe the healthcare system needs to build on such successes rapidly, without reinventing them.
Our overall conclusion is that Alberta provides some excellent care for individuals with chronic diseases. However, that care tends to be fragmented. No entity has overall responsibility for ensuring that all the parts work together well, that all patients receive the same level of care, and that providers are making good use of available resources to understand chronic diseases and manage patient care.
Our audit findings
- The Department of Health has not set expectations for the services that physicians, Primary Care Networks and Alberta Health Services should provide to individuals with chronic disease. It needs to define what service providers should be doing, and how it will determine whether intended results are being achieved.
- The Department of Health and Alberta Health Services do not have a process to identify individuals with chronic disease within physician practices or to determine the demand for chronic disease management services in the province as a whole. Knowing who suffers from chronic diseases is the first step toward improved management of these diseases.
- The Department of Health and Alberta Health Services have not taken sufficient responsibility for directing and coordinating chronic disease management. Much of the work of chronic disease management is currently left toPrimary Care Networks or even to individual physicians.
- Primary Care Networks do not offer consistent chronic disease management services across the province, or sometimes even within their own network. The networks receive good educational support from Alberta Health Services. However, Primary Care Networks do not have sufficient non-physician care team providers to deliver a full range of chronic disease management services. Family physicians who do not practice in Primary Care Networks have even less coordination and support.
- The Department of Health’s care plan initiatives have not been widely adopted or well implemented. One of every five patients with qualifying chronic conditions is recorded as having a care plan, and most of these care plans are not evaluated for effectiveness.
- The Department of Health and Alberta Health Services have not made the best use of the healthcare information they have available. In part, healthcare data has not been more widely used because providers may not understand what they can share. Enhanced use of healthcare data does not have to compromise personal privacy. Further advances in the use of technology in physician offices are also critical.
- Alberta Health Services could improve the management of its chronic disease management services and integrate these services with family physicians more thoroughly. Alberta Health Services is the default provider of care for chronic disease patients who do not have a regular physician, but it does not have processes to ensure these patients receive proper care.
- Chronic disease management services across the province are not assessed to measure whether they are achieving their intended results.
What needs to be done
Alberta has developed some good approaches to chronic disease management. However, these approaches can be improved. Several partial steps in the right direction need to be followed through to completion.
We recognize that improvement in CDM across the province will take time. For example, changing what is expected of service providers will require negotiation with professional regulating bodies. Patients will need to learn how to use new tools to better self?manage their chronic diseases. Systems to collect and analyze the information to assess effectiveness need to be developed at both the provider level and for the healthcare system overall.
We believe action needs to be taken immediately on all our recommendations. The following timeline provides our opinion on when implementation could be substantially complete:
Within 1 year ~ Recommendations to the Department of Health to:
- set expectations for CDM services to be provided by physicians, AHS and Primary Care Networks
- strengthen CDM supports to family physicians
- facilitate secure sharing of patient healthcare information among providers
- support all family physicians in identifying who their patients are and which patients have chronic disease
- set expectations for care plan delivery and strengthen the administration of care plan billings
- support family physicians and care teams in implementing better electronic medical record systems
~ Recommendations to Alberta Health Services to:
- develop a system to assess demand for CDM services across the province
- set provincial objectives and standards for its CDM services
- identify and provide care to patients who do not have a family physician until they can be linked with one
Within 2-3 years ~ Recommendations to the Department of Health to:
- request physicians to provide comprehensive team?based care to patients with chronic disease
- establish processes to assess the effectiveness of CDM services delivered by the providers it funds
- determine what it considers to be an effective care team size and composition, and work with family physicians, Primary Care Networks and other providers to help build teams to this level
- establish a formal process to integrate patient care plans prepared by physicians and pharmacists
- evaluate the effectiveness of care plans on an ongoing basis
- provide personal healthcare information to individuals with chronic disease, including their medical history and care plan
~ Recommendations to Alberta Health Services to:
- integrate its CDM services with those provided by physicians, Primary Care Networks and Family Care Clinics to avoid gaps and duplication
- coordinate its CDM services with patients’ care plans
- establish systems to measure and report the effectiveness of its CDM services
A copy of the report can be found on the office’s website.