Search

Background: An integrated chronic disease management model has been implemented across primary healthcare clinics in order to transform the delivery of services for patients with chronic diseases. The sustainability and rapid scale-up of the model is dependent on positive staff perceptions and experiences.Objectives: The aim of the study was to determine the perceptions and experiences of professional nurses with the integrated chronic care model that has been implemented.Method: A cross-sectional descriptive survey utilising a self-administered questionnaire was conducted amongst all professional nurses who were involved in delivering primary healthcare services at the 42 implementing facilities in September 2014. Each facility has between four and eight professional nurses providing a service daily at the facilitiesResults: A total of 264 professional nurses participated in the survey. Prior to the implementation, 34% (91) of the staff perceived the model to be an added programme, whilst 36% (96) of the staff experienced an increased workload. Staff noted an improved process of care, better level of interaction with patients, improved level of knowledge and better teamwork coupled with an improved level of satisfaction with the work environment at the clinic after implementation of the integrated chronic disease model.Conclusion: Professional nurses have a positive experience with the implementation of the integrated chronic disease management model.

Background: An 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.Aim: The aim of this study was to assess the sustainability of the facility reorganisation and clinical support components 18 months after the initiation.Setting: The study was conducted at 37 of the initiating clinics across three districts in three provinces of South Africa.Methods: The National Health Service (NHS) Institute for Innovation and Improvement Sustainability Model (SM) self-assessment tool was used to assess sustainability.Results: Bushbuckridge 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.Conclusion: The 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.

Background: Diagnostic health laboratory services are regarded as an integral part of the national health infrastructure across all countries. Clinical laboratory tests contribute substantially to health system goals of increasing quality of care and improving patient outcomes.Objectives: This study aimed to analyse current laboratory expenditures at the primary healthcare (PHC) level in South Africa as processed by the National Health Laboratory Service and to determine the potential cost savings of introducing laboratory demand management.Methods: A retrospective cross-sectional analysis of laboratory expenditures for the 2013/2014 financial year across 11 pilot National Health Insurance health districts was conducted. Laboratory expenditure tariff codes were cross-tabulated to the PHC essential laboratory tests list (ELL) to determine inappropriate testing. Data were analysed using a Microsoft Access database and Excel software.Results: Approximately R35 million South African Rand (10%) of the estimated R339 million in expenditures was for tests that were not listed within the ELL. Approximately 47% of expenditure was for laboratory tests that were indicated in the algorithmic management of patients on antiretroviral treatment. The other main cost drivers for non-ELL testing included full blood count and urea, as well as electrolyte profiles usually requested to support management of patients on antiretroviral treatment.Conclusions: Considerable annual savings of up to 10% in laboratory expenditure are possible at the PHC level by implementing laboratory demand management. In addition, to achieve these savings, a standardised PHC laboratory request form and some form of electronic gatekeeping system that must be supported by an educational component should be implemented.

Background: South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge.Methods: The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model.Results: The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes.Conclusion: The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process.

Background: Deficiencies in record keeping practices have been reported at primary care level in the public health sector in South Africa. These deficiencies have the potential to negatively impact patient health outcomes as the break in information may hinder continuity of care. This disruption in information management has particular relevance for patients with chronic diseases. Objectives: The aim of this study was to establish if the implementation of a structured clinical record (SCR) as an adjunct tool to the algorithmic guidelines for chronic disease management improved the quality of clinical records at primary care level. Method: A quasi-experimental study (before and after study with a comparison group) was conducted across 30 primary health care clinics (PHCs) located in three districts in South Africa. Twenty PHCs that received the intervention were selected as intervention clinics and 10 facilities were selected as comparison facilities. The lot quality assurance sampling (LQAS) method was used to determine the number of records required to be reviewed per diagnostic condition per facility. Results: There was a a statistically significant increase in the percentage of clinical records achieving compliance to the minimum criteria from the baseline to six months post-intervention for both HIV patients on antiretroviral treatment and patients with non-communicable diseases (hypertension and diabetes). Conclusions: A multifaceted intervention using a SCR to supplement the educational outreach component (PC 101 training) has demonstrated the potential for improving the quality of clinical records for patients with chronic diseases at primary care clinics 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.

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.

The integrated chronic disease management model provides a systematic framework for creating a fundamental change in the orientation of the health system. This model adopts a diagonal approach to health system strengthening by establishing a service-linked base to training, supervision, and the opportunity to try out, assess, and implement integrated interventions.

Background : Chronic diseases of lifestyle are detrimentally affecting South Africans. National Health Insurance, which is intended to improve care, requires capacity building for nurses at primary care clinics to ensure appropriate service provision. Objective : This study’s objective was to evaluate the impact of the ‘Primary Care 101’ chronic disease management guideline and training on nurses’ knowledge of chronic diseases management. Method : A population-based, unblinded, stratifid cluster randomised controlled trial with intervention ( n = 20) and control clinics ( n = 10) in three South African districts was conducted over six months in 2012. Nurses in the clinics participated in surveying knowledge on management of tuberculosis, human immunodefiiency virus infection, mental health, epilepsy, diabetes, hypertension and asthma and chronic obstructive pulmonary disease (COPD). All nurses were surveyed at baseline and six months later. Intervention clinic nurses were also surveyed immediately after training and three months post-training. Data were analysed using SPSS version 19 (SPSS Inc., Chicago, IL).Total mean knowledge percentage scores were calculated for each chronic disease. Mean knowledge percentage score changes between baseline and six months amongst all nurses and between intervention and control clinic nurses were compared using the paired samples t -test and independent samples t -test respectively. Results : There were signifiant improvements in nurses’ knowledge of hypertension and diabetes management over six months. Knowledge about asthma and COPD management decreased in all districts and nurse categories. Conclusion : The improvements in nurses’ knowledge can ensure improved patient management, but attention to asthma and COPD management is required. Agtergrond : Chroniese lewenstylsiektes beinvloed Suid-Afrikaners nadelig. Die nasionale gesondheidsversekering, wat ten doel het om sorg te verbeter, vereis kapasiteitsbou vir verpleegsters by primere-sorg-klinieke om sodoende toepaslike dienslewering te verseker. Doelwitte : Hierdie studie se doel was te evalueer wat die impak van die ‘ Primary Care 101 ’ chroniese siekte bestuursriglyn, asook opleiding is op verpleegsters se kennis van hoe om chroniese siektes te bestuur. Metode : ’n Bevolkingsgebaseerde, onverblinde, ewekansige gekontroleerde trossteekproef met ingrypings- ( n = 20) en kontrole-klinieke ( n = 10) is oor ’n tydperk van ses maande in 2012 in drie Suid-Afrikaanse distrikte uitgevoer. Verpleegsters in hierdie klinieke het deelgeneem aan ’n opname oor hul kennis oor die bestuur van tuberkulose, menslike immuniteitsgebreksvirus-infeksie, geestesgesondheid, epilepsie, diabetes, hoe bloeddruk, asook asma en chroniese obstruktiewe longsiekte (COPD). Alle verpleegsters is by die basislyn ondervra en ses maande later. Intervensie kliniekverpleegsters is ook ondervra onmiddellik na die opleiding en drie maande post-opleiding. Data is ontleed met behulp van SPSS, weergawe 19 (SPSS Inc, Chicago, IL). Totale gemiddelde kennis persentasietellings is vir elke chroniese siekte bereken. Veranderinge in die gemiddelde kennis persentasietellings tussen die basislyn en ses maande later is onder alle verpleegsters, asook tussen ingrypingsen kontrole-kliniekverpleegsters vergelyk met behulp van die gepaarde steekproef t -toets en die onafhanklike steekproef t -toets onderskeidelik. Resultate : Daar was ’n aansienlike verbetering in verpleegsters se kennis oor die bestuur van hoe bloeddruk en diabetes na ses maande. Kennis oor die bestuur van asma en COPD het in alle distrikte en verpleegster-kategoriee afgeneem. Gevoltrekking : Die verbetering in die verpleegsters se kennis kan verbeterde pasientbestuur verseker, maar die bestuur van asma en COPD vereis verdere aandag.