Download inca: het integraal chronisch zorgprogramma

INCA Model: Individualized care with an integral chronic care program
The challenges of chronic diseases
Non-communicable diseases (NCDs) are the main burden for health systems around the globe. Chronic
diseases in particular pose a serious threat to the wellbeing and finances of societies and individuals. The
main challenge with chronic care is that people cannot be cured from their disease. Focus is on limiting
progress and prolonging life with a (more than) acceptable quality of life. This has some consequences
patients and health systems have to cope with:
 Psychosocial impact: Chronic diseases have an enormous and a progressive impact on the life of
patients. Vice versa challenges in life and life events will have an impact on the disease
perception and behavior of patients. These impacts have to be taken into account with the care
plans. It is not only medical care, but also psychosocial support.
 Self-management support: Patients will be confronted with an increasing burden of their
disease(s). They have to be stimulated to be committed and compliant with lifestyles and
therapies to limit progress and complications they do not fully apprehend as yet.
 Co- and multimorbidity: Multiple diseases converge around the greying and chronically ill
population. Patients will eventually suffer from more than 1 disease. Disease management
aimed at managing one disease will not suffice. Patients have to be taken care of holistically from
an integral care program catering for multiple chronic diseases.
 Heterogeneous population: ‘The’ chronic patient does not exist. In reality it is a population of
people with one or more chronic diseases with multiple health related problems which come in
different combinations and grades of severity.
 Costs: The costs will rise with the technologic developments and demographic changes, since
they will lead to a growing and greying population necessitating more and more care.
Care Standard is not standard care
With growing challenges and the heterogeneous manifestation of health related problems to be taken
care of, there is always risk of differences in the care (quality) delivered. Minimal norms and
standardization are essential. For this reason Care Standards have been developed in the Netherlands.
These Care Standards describe which minimal norms have to be met with care for a particular condition
from the personal perspective of patients. They are based on the Chronic Care Model1 in which the
emphasis is on achieving a productive interaction between an activated patient with a proactive care
team. Although these standards universally apply to the care of each patient, it does not mean that the
care provided per patient has to be the same. To the contrary actually, because the population is in fact
heterogeneous in the health problems they have and experience. For example, some diabetics are
overweight whereas others are not, some smoke and some do not, some use insulin, other oral agents
and others no medication. What they all have in common is that they have health problems related to
their disease, partly disease specific and partly disease overarching. For each of these health problems,
the specific patient needs will have to be assessed to tailor care to the needs of the individual patient.
The Care Standards describes how these problems have to be addressed in productive interactions with
patients.
A major challenge when working with Care Standards is multi- and co-morbidity. Should a COPD patient
with diabetes receive care according to the COPD Care Standard, according to the Diabetes Care Standard
or both Care Standards? Apart from sometimes conflicting guidelines and protocols, there is considerable
overlap in particular with the lifestyle interventions. Care for multiple conditions has to be organized in
integral programs in which all relevant health problems can be taken care of in a holistic approach.
1
Wagner EH, Austin BT, Von Korff M. Organizing Care for Patients with Chronic Illness. Millbank Quarterly
1996;74:511-44
Copyright © 2015 ACSION B.V. All Rights Reserved
The INCA model, in which 'Stepped Care Modules' for the health problems of multiple diseases are
brought together in one program integral chronic care program, aims to individualize care for patients
with or without co- and multi-morbidity
The INCA model: Integral Care for chronic patients
The INCA model has been developed on behalf of the Ministry of Health in the Netherlands by ACSION
in collaboration with Casemix. The model does not primarily take the diagnosis (COPD, diabetes, etc.) of
a patient as starting point, but the specific health problems of the patient. The care is described in socalled ‘Stepped Care Modules’ (SCMs). For each health problem, both disease-specific, such as glycemic
control in diabetes, as well as disease-overarching, such as smoking and obesity, the care is described in
increasing intensity. In each module the following is described: objectives (the outcome to be achieved),
the care activities (diagnostic tests, lifestyle programs, care interventions and medication), what advice
the patient should get and how progress should be monitored. The minimal competencies required of
the caregiver(s) involved is also determined for each activity. It is up to the care group to determine who
will actually perform the activities.
The INCA model in practice
The patient’s medical and psychosocial situation is assessed as usual with a history, physical examination,
lab and additional function tests. The parameters of this assessment are translated by the INCA
Assessment tool to a Spider web as illustrated below.
Figure 1. The spider web in which the extent of each health problem is visualized on an axis from 1 to 10. A score of 10 indicates
that the problem is maximally present. The aim is to go from the larger 'blue web' to the smaller 'red web.
With the spider web patients and their caregivers can see at a glance where the greatest problems and
risks are allowing them to jointly decide on the approach. This Shared Decision Making (SDM) is a
prerequisite for the commitment of patients to comply with their own targets and treatment plans. By
periodically repeating the assessment disease progress or improvements are clearly visible. This can help
to (continuously) motivate patients.
In the SDM process the SCMs indicated for the patient are advised based on the INCA algorithms. The
life and treatment goals and the SCMs to achieve these are chosen. The selected SCMs are brought
together in a 'tailored' integral Individual Care Plan.
Copyright © 2015 ACSION B.V. All Rights Reserved
Figure 2. The integral chronic care program of INCA consists of the Assessment and Stepped Care Modules. Based on the
specific health problems of the patient, a tailored individual care plan is made by combining the selected SCMs. As in this
example: Smoke SCM 2, Weight loss SCM 3 and Hypertension SCM 3.
In the next step the logistics and data registration and communication is supported. Appointments are
scheduled with the different members of the care team. The relevant information and requests are
shared between care team members involved.
Advantages of INCA
For the patient
The holistic approach and tailoring of care to the specific needs of patients in a validated manner helps
to assure patients are taken care of based on their specific needs in life and in relation to their disease.
The major advantage for them is that they feel understood and in course of time their quality of life is
maintained.
Individual caregivers
The GP and specialized nurse have a validated instrument to support Shared Decision Making with
their patients and to motivate them to be committed and to comply with the needs of their disease
and life. They can also visualize the results of their efforts with this patient population. Furthermore
the multidisciplinary team members have the right information at the right moment.
Copyright © 2015 ACSION B.V. All Rights Reserved
For internal management of healthcare groups and population management
Since all data and choices are electronically registered the total of all individual care profiles can easily
be aggregated. This provides an accurate picture of the case mix and the nature and volume of the
care to be delivered by a healthcare group based on the actual health needs of their chronically ill
population. This offers great advantages. For example you can determine the actual health problems
in a population. You can also identify the room for improvement in the health status of that population,
which care should be provided and what competencies (healthcare professionals) have to be procured
to deliver this care. Hence multidisciplinary healthcare groups can manage their organization,
processes, quality and financing based on the aggregated individual profiles.
Payers
Most important for payers is that the care delivered was indicated and necessary. If not, they pay for
unnecessary care. The fact that the care to be delivered is assessed bottom up in the individual care
process and then aggregated to population level ensures that appropriate care is provided and
procured. The costs for medication, laboratory tests and referrals are mainly driven by chronic diseases
like diabetes and cardiovascular diseases. It is to be expected that part of these expenses is waste
because of unnecessary prescription, lab test and referrals. This can be avoided when the care is
coordinated and registered electronically. Moreover, when these patients are taken care of
structurally, costly complications, such as myocardial infarction, dialysis and amputations as well as
hospitalizations can be avoided.
Furthermore, uniformity in chronic care programs from different care providers is desirable for
decision making in the procurement process. Otherwise payers have to assess the programs every time
again.
Governments
Optimal care is delivered, waste is avoided and a clear morbidity and care needs registration. Based
on the latter capacity can be planned on a regional or national level.
Current status of the INCA model
The development of the INCA model is going into its 3rd phase:
1. Phase 1: Development of the Assessment and Stepped Care Modules (2010-2012)
2. Phase 2: Pilots to test model with retrospective data of care practices (2013-2014)
3. Prospective pilots with the INCA model in real patient care in 4 care groups
So far INCA has been received enthusiastically by patients, their care providers, care group managers
and health insurers. Reason why they want to test the model further and tailor it for widespread use.
Copyright © 2015 ACSION B.V. All Rights Reserved