Integrated Chronic Disease Management Research Articles

Professional nurses' perspectives on the implementation of integrated chronic disease management model.

The integrated chronic disease management (ICDM) model is seen to be a promising strategy as it is gaining global acceptance as an approach to enhance healthcare delivery. The study objectives were to explore and describe professional nurses' perspectives on the model, identify challenges experienced during implementation and identify factors that could improve the model implementation. An explorative, descriptive qualitative design was used, nine professional nurses from three selected facilities were interviewed. Data obtained from semi-structured individual interviews were analysed using thematic analysis and NVivo software. Three main themes emerged: the professional nurses' perceived benefits of the model, challenges experienced during implementation and recommendations to ensure effective implementation of the model. The perceived benefits of the model included the integration of care, adequate medication and the alleviation of stigma related to diseases. However, the challenges of the model included a shortage of staff, poor infrastructure and patients missing scheduled appointments. The study noted the need for adequate staff, infrastructure and ongoing training for the successful implementation of the model. Despite challenges in the South African healthcare system, professional nurses perceived the implementation of the model positively. The study highlighted the need for adequate staff, adequate infrastructure and ongoing training for staff.Contribution:This study outlined the challenges and recommendations identified, enabling healthcare organisations, policymakers and educators to develop targeted strategies for successful implementation. The findings will also inform future research focussed on optimising the utilisation of the model in the study setting and similar contexts.

Why the incidence in dialysis in the Lisbon and Tagus Valley Region (LVTR) is two to three times higher than in other regions of the country

The analysis of data from the Ministry of Health’s Integrated Chronic Kidney Disease Management Platform (PI -GID), reveals the existence of a striking regional difference in the incidence in dialysis. This difference is characterized by high levels of incidence in all regions, except the Alentejo, and extremely high levels in the Lisbon and Tagus Valley region. In this region, the incidence values are two to three times higher than in the others. The difference between regions is the result of a different number of patients starting hemodialysis, since the incidence in peritoneal dialysis is low and similar in all of them. It is difficult to find justification for such a discrepancy since the prevalence of factors usually responsible for the higher or lower level of incidence in dialysis does not differ significantly between them. A probable explanation may lie in the difference found in the concentration of public hemodialysis centers, a fact that may determine a difference in the criteria used for the entry of patients undergoing substitutive treatment of renal function. In fact, we found a close correlation between the number of public hemodialysis centers per million inhabitants and the level of incidence in dialysis. A more comprehensive analysis of the data from the Ministry of Health’s Integrated Chronic Kidney Disease Management Platform (PI -GID), if allowed, would be of enormous interest, not only to explain this discrepancy in the incidence of dialysis between regions, but because it could probably allow an explanation for Portugal having (one of) the highest levels of dialysis incidence in Europe

Multilevel predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in rural South Africa: a panel study

ObjectiveIn 2011, The National Department of Health introduced the Integrated Chronic Disease Management (ICDM) model as a pilot programme in selected primary healthcare facilities in South Africa. The objective of...

Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: Viewpoints of service users and providers.

BackgroundAn integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa.Materials and methodsA content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software.ResultsThe emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives.ConclusionsAlthough the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.

A mixed methods approach to exploring the moderating factors of implementation fidelity of the integrated chronic disease management model in South Africa

BackgroundChronic care models like the Integrated Chronic Disease Management (ICDM) model strive to improve the efficiency and quality of care for patients with chronic diseases. However, there is a dearth of studies assessing the moderating factors of fidelity during the implementation of the ICDM model. The aim of this study is to assess moderating factors of implementation fidelity of the ICDM model.MethodsThis was a cross-sectional mixed method study conducted in two health districts in South Africa. The process evaluation and implementation fidelity frameworks were used to guide the assessment of moderating factors influencing implementation fidelity of the ICDM model. We interviewed 30 purposively selected healthcare workers from four facilities (15 from each of the two facilities with lower and higher levels of implementation fidelity of the ICDM model). Data on facility characteristics were collected by observation and interviews. Linear regression and descriptive statistics were used to analyse quantitative data while qualitative data were analysed thematically.ResultsThe median age of participants was 36.5 (IQR: 30.8–45.5) years, and they had been in their roles for a median of 4.0 (IQR: 1.0–7.3) years. The moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). One feature of the ICDM model that seemingly compromised fidelity was the inclusion of tuberculosis patients in the same stream (waiting areas, consultation rooms) as other patients with non-communicable diseases and those with HIV/AIDS with no clear infection control guidelines. Participants also suggested that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure, adequate staff, and balanced patient caseloads.ConclusionThere are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Augmenting facilitation strategies (training and clinical mentorship) could further improve the degree of fidelity during the implementation of the ICDM model.

Organisational culture and the integrated chronic diseases management model implementation fidelity in South Africa: a cross-sectional study

ObjectiveTo assess whether organisational culture influences the fidelity of implementation of the Integrated Chronic Disease Management (ICDM) model at primary healthcare (PHC) clinics.DesignA cross-sectional study.SettingThe ICDM model was introduced in...

The cost and cost implications of implementing the integrated chronic disease management model in South Africa.

A cost analysis of implementation of interventions informs budgeting and economic evaluations. To estimate the cost of implementing the integrated chronic disease management (ICDM) model in primary healthcare (PHC) clinics in South Africa. Cost data from the provider's perspective were collected in 2019 from four PHC clinics with comparable patient caseloads (except for one). We estimated the costs of implementing the ICDM model current activities for three (facility reorganization, clinical supportive management and assisted self-management) components and additional costs of implementing with enhanced fidelity. Costs were estimated based on budget reviews, interviews with management teams, and other published data. The standard of care activities such as medication were not included in the costing. One-way sensitivity analyses were carried out for key parameters by varying patient caseloads, required infrastructure and staff. Annual ICDM model implementation costs per PHC clinic and per patient per visit are presented in 2019 US dollars. The overall mean annual cost of implementing the ICDM model was $148 446.00 (SD: $65 125.00) per clinic. Current ICDM model activities cost accounted for 84% ($124 345.00) of the annual mean cost, while additional costs for higher fidelity were 16% ($24 102.00). The mean cost per patient per visit was $6.00 (SD:$0.77); $4.94 (SD:0.70) for current cost and $1.06 (SD:0.33) for additional cost to enhance ICDM model fidelity. For the additional cost, 49% was for facility reorganization, 31% for adherence clubs and 20% for training of nursing staff. In the sensitivity analyses, the major cost drivers were the proportion of effort of assisted self-management staff and the number of patients with chronic diseases receiving care at the clinic. Minimal additional cost are required to implement the ICDM model with higher fidelity. Further research on the cost-effectiveness of the ICDM model in middle-income countries is required.

Patient-Centred Care for Patients With Diabetes and HIV at a Public Tertiary Hospital in South Africa: An Ethnographic Study.

Background: Healthcare systems across the globe are adopting patient-centred care (PCC) approach to empower patients in taking charge of their illnesses and improve the quality of care. Although models of patient‐centredness vary, respecting the needs and preferences of individuals receiving care is important. South Africa has implemented an integrated chronic disease management (ICDM) which has PCC component. The ICDM aims to empower chronic care patients to play an active role in disease management process, whilst simultaneously intervening at a community/ population and health service level. However, chronic care is still fragmented due to systemic challenges that have hindered the practice of PCC. In this article, we explore provider perspectives on PCC for patients with comorbid type 2 diabetes and HIV at a public tertiary hospital in urban South Africa. Methods: This study utilizes ethnographic methods, encompassing clinical observations, and qualitative interviews with healthcare providers (n=30). Interview recordings were transcribed verbatim and data were analyzed inductively using a grounded theory approach. Results: Providers reported various ways in which they conceptualized and practiced PCC. However, structural challenges such as staff shortages, lack of guidelines for comorbid care, and fragmented care, and patient barriers such as poverty, language, and missed appointments, impeded the possibility of practicing PCC. Conclusion: Health systems could be strengthened by: (i) ensuring appropriate multidisciplinary guidelines for managing comorbidities exist, are known, and available, (ii) strengthening primary healthcare (PHC) clinics by ensuring access to necessary resources that will facilitate successful integration and management of comorbid diabetes and HIV, (iii) training medical practitioners on PCC and structural competence, so as to better understand patients in their sociocultural contexts, and (iv) understanding patient challenges to effective care to improve attendance and adherence.

Evaluation of an integrated HIV and hypertension management model in rural South Africa: a mixed methods approach

ABSTRACT Background: A summary of Soter Ameh’s PhD thesis titled, ‘An integrated HIV and hypertension management model in rural South Africa: A mixed methods approach’ is presented here. In responding to the dual high burden of non-communicable diseases (NCDs) and HIV in South Africa, the national government initiated an integrated chronic disease management (ICDM) model in health facilities as a pilot programme. The aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs to improve the quality of care and health outcomes of adult patients. Objectives: The specific objectives of this study were to: (1) determine the quality of care provided in the integrated model in 2013, (2) describe patients’ and operational managers’ perceptions of quality of care in the integrated model in 2013, and (3) assess effectiveness of the integrated model in controlling CD4 counts (>350 cells/mm3) and blood pressure (<140/90 mmHg) of patients from 2011 to 2013. Methods: A combination of quantitative and qualitative methods was used to assess and describe the quality of care in the model. Effectiveness of the model in controlling patients’ blood pressure (BP) and CD4 counts was assessed in selected PHC facilities in the Bushbuckridge municipality in Mpumalanga province, South Africa. Results: The findings showed the suboptimal quality of care in five of the eight priority dimensions of care used as leverage for the NCD programme. The ICDM model had a small but significant effect on BP control for hypertension patients receiving treatment. Conclusions: The HIV programme needs to be more extensively leveraged for hypertension treatment to achieve an optimal BP control in the study area. These findings could have policy relevance for low- and middle-income countries currently undertaking proof of concept studies to demonstrate the feasibility of implementing an integrated chronic disease care model.

Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa

BackgroundThe Integrated Chronic Disease Management (ICDM) model has been implemented in South Africa to enhance quality of clinical services in Primary Healthcare (PHC) clinics in a context of a high prevalence of chronic conditions and multi-morbidity. This study aimed to assess the implementation fidelity (adherence to guidelines) of the ICDM model.MethodsA cross-sectional study in 16 PHC clinics in two health districts in South Africa: Dr. Kenneth Kaunda (DKK) and West Rand (WR). A fidelity assessment tool with 89 activities and maximum score of 158 was developed from the four interrelated ICDM model components: facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems. Value stream mapping of patient flow was conducted to analyse waiting time and identify operational inefficiencies. ICDM items were scored based on structured observations, facility document reviews and structured questionnaires completed by healthcare workers. Fidelity scores were summarized using medians and proportions and compared by facilities and districts using Chi-Square and Kruskal Wallis test.ResultsThe monthly patient headcount over a six-month period in these 16 PHC clinics was a median of 2430 (IQR: 1685–2942) individuals over 20 years. The DKK district had more newly diagnosed TB patients per month [median 5.5 (IQR: 4.00–9.33) vs 2.0 (IQR: 1.67–2.92)], and fewer medical officers per clinic [median 1 (IQR: 1–1) vs 3.5 (IQR:2–4.5)] compared to WR district. The median fidelity scores in both districts for facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems were 78% [29/37, IQR: 27–31)]; 77% [30/39 (IQR: 27–34)]; 77% [30/39 (IQR: 28–34)]; and 80% [35/44 (IQR: 30–37)], respectively. The overall median implementation fidelity of the ICDM model was 79% (125/158, IQR, 117–132); WR was 80% (126/158, IQR, 123–132) while DKK was 74% (117/158, IQR, 106–130), p = 0.1409. The lowest clinic fidelity score was 66% (104/158), while the highest was 86% (136/158). A patient flow analysis showed long (2–5 h) waiting times and one stream of care for acute and chronic services.ConclusionThere was some variability of scores on components of the ICDM model by PHC clinics. More research is needed on contextual adaptations of the model.

P3817Predictors of controlled CD4 count and blood pressure in an integrated chronic disease management model in a rural South African setting

Abstract Background South Africa is undergoing an epidemiological transition with a dual burden of chronic communicable and non-communicable diseases. A pilot integrated chronic disease management (ICDM) model was initiated in 2011 by the National Department of Health in selected primary health care (PHC) facilities. The aim of the ICDM model is to leverage an established HIV treatment programme for non-communicable diseases (NCDs) for better health outcomes of patients with chronic diseases. Purpose This study determined predictors of controlled CD4 count and blood pressure (BP) in hypertension and HIV patients receiving antihypertension medication and antiretroviral drugs, respectively in PHC facilities in the Bushbuckridge sub-district of Mpumalanga province, South Africa. Methods This was a panel study to assess the effectiveness of the ICDM model in controlling patients' CD4 count and BP. Patients ≥18 years were recruited through a three-step sampling process into the ICDM model facilities (n=435) and comparison facilities (n=443) in the Bushbuckridge sub-district. Health outcome data (BP and CD4 counts) for each patient were retrieved from health facility records over 30 months (January 2011 to June 2013). Control of BP and CD4 counts were defined as BP &lt;140/90 mmHg and CD4 counts &gt;350 cells/mm3, respectively. Multilevel logistic regression analyses were conducted to determine predictors of controlled CD4 count and controlled hypertension. Data were analysed using Stata 14 statistical software. Results The odds of controlling CD4 count were increased by reception of care at the ICDM model facilities (OR=4.05, 95% CI: 2.77–5.92), but decreased by male gender (OR=0.52, 95% CI: 0.34–0.80). The odds of controlling hypertension were higher with increasing age: 40–49 years (OR=6.02, 95% CI: 2.07–17.57); 50–59 years (OR=23.17, 95% CI: 7.46–72.16); ≥60 years (OR=77.48, 95% CI: 25.03–82.26), but decreased by male gender (OR=0.38, 95% CI: 0.21–0.69). Conclusion Application of the ICDM model appeared effective in controlling patients' CD4 counts, but not their BP; hence, the HIV programme should be more extensively leveraged for hypertension treatment in health facilities in the study setting. Health education programmes to improve HIV treatment outcomes should focus on males. Hypertension educational programmes should target younger males in the study setting. Acknowledgement/Funding Fogarty International Centre of the National Institutes of Health under the Award number D43 TW008330

Process evaluation of fidelity and costs of implementing the Integrated Chronic Disease Management model in South Africa: mixed methods study protocol

IntroductionThe South African Department of Health has developed and implemented the Integrated Chronic Disease Management (ICDM) model to respond to the increased utilisation of primary healthcare services due to a...

Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis.

South Africa faces a dual burden of HIV/AIDS and noncommunicable diseases. In 2011, a pilot integrated chronic disease management (ICDM) model was introduced by the National Health Department into selected primary health care (PHC) facilities. The objective of this study was to assess the effectiveness of the ICDM model in controlling patients' CD4 counts (>350 cells/mm) and blood pressure [BP (<140/90 mm Hg)] in PHC facilities in the Bushbuckridge municipality, South Africa. A controlled interrupted time-series study was conducted using the data from patients' clinical records collected multiple times before and after the ICDM model was initiated in PHC facilities in Bushbuckridge. Patients ≥18 years were recruited by proportionate sampling from the pilot (n = 435) and comparing (n = 443) PHC facilities from 2011 to 2013. Health outcomes for patients were retrieved from facility records for 30 months. We performed controlled segmented regression to model the monthly averages of individuals' propensity scores using autoregressive moving average model at 5% significance level. The pilot facilities had 6% greater likelihood of controlling patients' CD4 counts than the comparison facilities (coefficient = 0.057; 95% confidence interval: 0.056 to 0.058; P < 0.001). Compared with the comparison facilities, the pilot facilities had 1.0% greater likelihood of controlling patients' BP (coefficient = 0.010; 95% confidence interval: 0.003 to 0.016; P = 0.002). Application of the model had a small effect in controlling patients' CD4 counts and BP, but showed no overall clinical benefit for the patients; hence, the need to more extensively leverage the HIV program for hypertension treatment.

Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model

BackgroundSouth Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients’ and operational managers’ satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian’s theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care.MethodsA cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian’s theory, using unidirectional, mediation, and reciprocal pathways.ResultsThe mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs.ConclusionOf the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian’s theoretical framework can be used to provide evidence of quality systems in the ICDM model.

Sustainability of the integrated chronic disease management model at primary care clinics in South Africa.

BackgroundAn integrated chronic disease management (ICDM) model consisting of four components (facility reorganisation, clinical supportive management, assisted self-supportive management and strengthening of support systems and structures outside the facility) has been implemented across 42 primary health care clinics in South Africa with a view to improve the operational efficiency and patient clinical outcomes.AimThe aim of this study was to assess the sustainability of the facility reorganisation and clinical support components 18 months after the initiation.SettingThe study was conducted at 37 of the initiating clinics across three districts in three provinces of South Africa.MethodsThe National Health Service (NHS) Institute for Innovation and Improvement Sustainability Model (SM) self-assessment tool was used to assess sustainability.ResultsBushbuckridge had the highest mean sustainability score of 71.79 (95% CI: 63.70–79.89) followed by West Rand Health District (70.25 (95% CI: 63.96–76.53)) and Dr Kenneth Kaunda District (66.50 (95% CI: 55.17–77.83)). Four facilities (11%) had an overall sustainability score of less than 55.ConclusionThe less than optimal involvement of clinical leadership (doctors), negative staff behaviour towards the ICDM, adaptability or flexibility of the model to adapt to external factors and infrastructure limitation have the potential to negatively affect the sustainability and scale-up of the model.

Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.

The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model.In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis.The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic.Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.

Implementation of an Integrated Chronic Disease Management Model in South Africa

Introduction: Whilst chronic disease management of non-communicable diseases and mental health within primary care is and has been provided in primary care for many years, in many instances the health system has put greater emphasis on the relief of acute symptoms to the detriment of prevention and optimal care of chronic conditions. Moreover chronic disease services are primarily run as disease specific entities and hence programmes treat specific diseases rather than the whole person. Practice and context: An integrated chronic disease management (ICDM) model was proposed as a vehicle to improve the management of chronic conditions. The ICDM consists of four interrelated phases that are dependent on overarching strong stewardship and ownership at all levels of the health system (Figure 1). The four inter-related phases include: • Facility re-organisation to improve service efficiency. • Clinical supportive management to improve quality of clinical care. • “Assisted “self-support and management of patients through the ward based outreach teams (WBOT) to empower individuals to take responsibility for managing their own conditions and increasing awareness of chronic diseases at the population level • Health system strengthening Aim of the intervention: The aim of the ICDM is to achieve optimal clinical outcomes for patients with chronic diseases and improve the operational efficiency of the PHC clinics. The model was implemented between April 2011 and February 2013, at 42 public health sector clinics in three districts Approach: We used the clinical practice improvement model (CPI) for continuous quality improvement to implement components of the breakthrough series (BS) model Results: Fourteen facilities have shown a decrease in the median total time spent by patients across all diagnostic conditions from the baseline in December 2011. The total median time that World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116682– http://www.ijic.org/ chronic patients spent at the facilities in January 2013 decreased from both the baseline in December 2011 and intermediate measurement in May 2012 at 17 of the facilities. Fifty percent of the facilities have shown a decrease greater than 30% in the total time spent by chronic patients from the baseline in December 2011 and a decrease greater than 35% in the total time spent by chronic patients between May 2012 and January 2013. Discussion: Key requirements for implementing and sustaining change are change management; project planning and the use of quality improvement tools and these together with health service ownership were the central themes that resonated throughout the implementation process. Despite every effort to take cognisance of and address potential barriers, the implementation of the ICDM was dependent on the leadership capabilities of the operational managers. Cross messages from the various programme managers and the reluctance of the designated HIV/AIDS nurses that initiated and managed only HIV/AIDs patients created some organisational resistance. Systemic challenges inherent in the health system negatively impacted on the smooth implementation of the ICDM model. The lack of adequate essential equipment required at the facility posed a major challenge. The lack of financial resources and the procurement of poor quality equipment without a maintenance plan in place hindered the process. The health services is still very focussed at a curative health service level, with inadequate emphasis on primary prevention, health promotion and empowering the communities and patients to take responsibility for their individual health. Conclusion: The implementation of the ICDM is feasible at primary care in South Africa provided that systemic challenges and appropriate change management is not neglected.

An Integrated Chronic Disease Management Model- A diagonal approach to health system strengthening

South Africa is facing a complex burden of disease arising from a combination of rapidly growing chronic infectious illness (driven by HIV/AIDS) and non-communicable diseases (NCDs). The extent of this burden has few global parallels and demands an extraordinary response (1). A recent publication of a multi-centre prospective cross-sectional survey of consultations in primary care in four provinces of South Africa: Western Cape, Limpopo, Northern Cape and North West indicated that Hypertension, HIV/AIDS, Type 2 Diabetes and Tuberculosis (TB) were the most common conditions in terms of chronic care visits (2) The unprecedented roll out of antiretroviral treatment (ART) has transformed HIV / AIDS into a chronic disease, as people with HIV are living longer andageing, and are developing non-HIVrelated chronic conditions similar to the rest of the population. Some NCDs are related to HIV infection itself and to the side effects of some of the medicines used to treat HIV infection (3). Providing affordable and effective care to the often large and increasing numbers of people is already an immense challenge but as the burden of chronic diseases both (communicable and NCDs) increases, this will become an even bigger problem requiring a different and innovative approach. Whilst chronic disease management of NCDS and mental health within primary care is and has been provided in primary care for many years, in many instances the health system has put greater emphasis on the relief of acute symptoms to the detriment of prevention and optimal care of chronic conditions. Moreover chronic disease services are primarily run as disease specific entities and hence programmes treat specific diseases rather than the whole person. Where an individual has more than one condition they often need to attend on different days of the week and be seen by a different practitioner with consequences not only for patient care but costs to patient in terms of time and transport. The successful management of chronic diseases requires coordination of services for individuals over an extended time period and across disciplines and is dependent on a strong health system and innovative, robustly supported service delivery models that promote patient empowerment (4). Leveraging on the innovations of the HIV program and utilising South Africa’s recently adopted policy for re-engineering primary health care an integrated chronic disease management (ICDM) World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116681– http://www.ijic.org/ model, based on the WHO health system building blocks was proposed as a vehicle to improve the management of chronic conditions. The aim of the ICDM is to achieve optimal clinical outcomes for patients with chronic communicable and non-communicable diseases in order to respond to the growing burden in an efficient and cost effective manner (5). The ICDM is designed using a Public Health approach to empower the individual to take responsibility for their own health whilst simultaneously intervening at a community/population and health service level. The model was developed through a combination of initial theoretical and academic considerations over a two year period. The ICDM consists of four inter-related phases that are dependent on overarching strong stewardship and ownership at all levels of the health system l The four inter-related phases include: • Facility re-organisation to improve service efficiency. • Clinical supportive management to improve quality of clinical care. • “Assisted “self-support and management of patients through the ward based outreach teams (WBOT) to empower individuals to take responsibility for managing their own conditions and increasing awareness of chronic diseases at the population level • Strengthening of support systems and structures outside the facility to ensure a fully functional and responsive health system. Achieving an integrated chronic care disease management model requires a new way of thinking and acting. It is imperative that this model is piloted at a limited number of sites to assess the feasibility and sustainability whilst simultaneously evaluating the outcomes of chronic patients managed within the model. The lessons gained from the pilot sites can be used to further develop the model and scale up the implementation to saturate all districts in the country.

Integrated Disease Management Programs: Reflections and Learnings from Implementation

Integrated Chronic Disease Management (ICDM) is a key focus of recent Victorian Government primary care partnership (PCP) and community health policy direction documents. Planning for a more ICDM approach has been informed by earlier integrated disease management (IDM) projects funded through the PCP Strategy. In 2001, five IDM pilot projects were funded, for three years, under the Department of Human Services (Victoria) IDM Initiative. The IDM projects aimed to inform future planning for chronic disease care by developing models of care that sought a better quality of life, fewer complications for individuals, and reduced overall use of health care resources. The projects trialled different processes and components of IDM to accommodate local priorities, resources and existing care practice with more than 1000 consumers collectively involved. The experience of building community programs targeting consumers with chronic disease resulted in key learnings about IDM and effecting change. Enablers and barriers were identified, and the relationship between best practice and key learnings explored in the areas of partnerships, service coordination and consumer engagement, to further understand the best approaches to improve care for people with chronic disease.