Dalhousie varsity: Pakistani doctor develops generic care plan model for CDM


CHRONIC diseases are long-term conditions that cannot be eradicated and can only be treated symptomatically. The impact of chronic disease is multi-axial on both the individual and community levels. On individual level, the impact of chronic disease affects the quality of life which would ultimately affect the activities of daily living. The treatment of chronic diseases is longitudinal then episodic like in acute care. An important aspect of this longitudinal care is the development of the care plan to treat the chronically ill patient. Care planning is an essential component of chronic disease management.

These contents are part of a thesis entitled “Characterization Of A Longitudinal Care Plan Model For Managing Chronic Diseases: A Care Plan Ontology To Computerize Paper- Based Care Plans”, written by a Dowitte,DrShirin Sharif, M.D.,while doing her Masters in Health Informatics from Canada’s Dalhousie University, Faculties of Computer and Medicine in March 2012.  Dr. RazaAbidi of the same university was her research works supervisor. Both DrShirinand her husband, Dr Ali Haider, who are currently settled in Canada, did their masters in health informatics from Dalhousie University Halifax, Nova Scotia.

Elaborating on the subject of chronic diseases, DrShirin in her thesis inter alia states:“Conditions that last for more than six (06) months or more are referred to as chronic diseases. Chronic diseases not only have a major impact on the quality of life, but they also have adverse effects on families, communities, and societies. Chronic diseases do not necessary kill a person, but they affect both patients and their communities in twoways:Threaten the quality of life of patients with chronic disease by limiting their activities of daily living. The impact of this is multi-faceted because sometimes the chronically ill patients are unable to perform their daily routine work by themselves and need assistance. This situation not only affects the patient‘s physical condition, but also severely affects his/her psychological, economical, emotional and sociallife.

Pointing out the increasing burden of chronic disease is one of the greatest challenges that health systems will face globally in the 21st Century, she says that chronic diseases are the largest cause of death in the world.

Quoting a WHO (2010) report which estimates that about 72 per cent of all physician visits and around 76pc of hospital admissions are due to the patients with chronic disease, she states: “A large number of healthcare services are utilized for the management of chronic illnesses. Healthcare spending increases proportionally as the number of patients with multiple chronic conditions increase. It is being noted that healthcare spending for a person with a chronic condition is twice than that of a person without any chronic condition.

Referring to a 1998 survey, she said: “Patients with chronic disease utilize about 78pc of healthcare spending.HoffmanandRicein1996foundthatalmost44pcofpatientswithchronic diseases had more than one chronic condition and it is expected that by 2020, 81 million people will have more than one chronic condition.

According to a study conducted in US, in which functional status and well-being of chronic disease patients were compared with those without any chronic conditions, patients with chronic conditions suffer from decreased physical and social functioning. Chronic Diseases in Canada: Chronic diseases are posing a major threat to healthcare services and resources. Various reports show that the leading cause of morbidity and mortality in Canada is chronic disease and, according to a report published in 2004, 153,000 Canadians die each year due to chronicdiseases.

CATEGORIES: There are seven major categories of chronic illness which cause major utilization of healthcare services in Canada. They are:Endocrine disorders (especiallydiabetes); cardiovasculardiseases; chronic obstructive pulmonarydiseases, diseases of nervous system (multiple sclerosis, cerebral palsy, etc.), plus cancers, musculoskeletal disorders (osteoporosis,arthritis) and mental illness(Depression,Schizophrenia).

The direct cost of the management of the above seven diseases categories is $38.9 billion per year in Canada which includes the cost of drugs, physician services, hospitalization, home care medicines and private medical expenditures.

Moreover, in a survey conducted by Mathematic Policy Research in 2001, it was reported by physicians that the current healthcare system is not organized to treat chronic disease patients. It is hard for patients to access services at the time of need. Even if they are able to receive care for their chronic illnesses; this care is not well-coordinated which results in (a) duplication of diagnostic tests, (b) nursing home placements, (c) unnecessary hospitalizations which eventually results in the misuse of services and an increase in the burden on theeconomy.

Hence, it is recommended that patients with long-term conditions should have a care plan for their health. These care plans should help inproviding best counter measures to prevent the progression of chronic diseases. For this reason care plans are generated in collaboration with patients to guide them in managing their long-term conditions in a better and planned manner.

Definition of Care Plans: There are a number of definitions of care plans, such as“Number of strategies designed to guide health care professionals involved with patient care. Such plans are patient-specific and are meant to address the total status of patient. Care plans are intended to ensure optimal outcomes for patients during the course of their care.

Key Stages of Care Plan: According to National Health Service, key stages identified in care planning procedureinclude:Patient entry into the health care system is starting point of the care planning process, in which patient with chronic disease enters into thehospital.

Types of Care Plan:Nursing Care Plan: It is basically a written plan of patient care based on nursing diagnosis. It helps to provide appropriate care to patients and to keep track of their progress.

These include Patient Care Plan,Advance Care Plan, Multidisciplinary Care Plan, etc.Care plans can be generic without any details and complexities or they can be detailed and individualized depending on the complexity of a chronic disease. For example, Care Plan for an elderly patient having multiple chronic conditions like asthma, diabetes and arthritis would have more complex details of medications, lists of procedures to perform at home and in addition would also include tasks to handle emergency situations. On the other hand, care plan of a patient, who is young and fit with asthma, would only include how to use inhalers, goals to quit smoking, and referral to places where health care workers can help to quit smoking.

Personalized Care Planning: When a patient with a chronic disease enters into the healthcare system, his/her care plan is generated based on the current state of the disease. This patient-specific care plan is known as a personalized care plan and it includes (1) health profile (2) description of the patient‘s present health condition (3) details of risk assessment and (4) interventions or procedures  required for the management of chronic disease-specific to a particular patient.

Personalized care planning is especially important for diabetes because in diabetesthemessageisloudandclearthat―notwopeopleareexactlyalike. Asitis an endocrine disorder, it involves hormone action which is different for each individual. This hormonal action, different human behaviour and different diabetes complications causes a variety of responses to diabetes.

After thorough literature review of care plans and personalized care planning, most of the studies show that care planning for chronic diseases is longitudinal care process and starts with patient entry into the healthcare system, DrShirin states, saying “Our goal is to capture the longitudinal care planning process of chronic disease management and our research suggests that proper care planning starts from the time when patient with the chronic disease enters into the healthcare system. “As our aim is to develop knowledge model for chronic disease management, our generic model should include each piece of information generated during the care process. By capturing all the information, the knowledge model functions in a multifaceted manner which is (a) helping healthcare providers in their decision-making process and (b) helping the patient to attain control on their condition by receiving patient education, which makes the model patient-centric. Although it is suggested through studies that care plans can be generated in collaboration with a single health care professional, to get the real benefit of care planning, it should involve multiple healthcare providers for example, GPs, nurses, surgeons, chemotherapists, radiotherapists, social workers and even family members.”

Computerization of Care Plans: The concept of computerizing nursing care plans started in late 60‘s. In the past, the two approaches used for computerizing purposes were a) forms which are computer readable, in this approach actions listed on the forms are indicated by the nurses and b) Computer-generated standard care plans which are adjusted by the nurses for each patient. System based on second approach was developed in California hospital and was named as Technicon.Several computer-assisted systems were developed at hospitals in Arizona, Texas and North Carolina which were built on databases. Later in the 80‘s, several other systems were developed for computerization of nursing care plans.

The majority of the systems developed for computerization of nursing care plans were rule-based systems. Currently computerized systems available for managing chronic conditions include K4 healthcare model for providing home care services for elderly patients with long- term conditions. K4 is an ontology-based system and helps in providing a life cycle of personalized care planning process in home care. “Our proposed work differs from the K4 care model in having a sequence of clinical activities involved in chronic disease management for individuals of any age, taking place in hospital, home or nursing homes,whereas the K4 healthcare model is specially designed for assisting elderly patients at home.

Generic Care Plan Model:The intent of the generic Care Plan is to identify the salient (a) care plan concepts, such as care steps, care tasks, role of care providers, schedule of care tasks and their outcomes; (b) the functional and medical relationships between the care tasks leading to the definition of a care plan; and (c) disease-and-institution-specific constraints to care planning. The generic care plan model will subsequently be used to develop Care Plan ontology.

It may be noted that the medical literature does not provide a generic Care Plan structure, rather in a clinical setting the care planning process is an ad hoc exercise that is based on the patient‘s conditions, the care provider‘s knowledge and the hospital‘s care practices. For our purposes, we want to specify a generic, high-level care plan structure— highlighting the constituent activities, practitioners involved, intermediate results, timing and resource constraints and expected outcomes—that can be used to specify the longitudinal care process for a chronic disease.

“Our model is a combination of chronic disease management and care planning, so the generic care plan model should begin with a health care encounter of a chronic disease patient. By encapsulating the essential component of chronic disease management in this model we try to achieve a systemic presentation of the knowledge which is generated during the care process. At the same time, the generic model should also provide step by step recommendations to guide the care process. The starting point of our research is investigating the commonalities like tasks, activities, roles, etc. that occur in chronic disease management and care planning. After determining the commonalities these were incorporated into the generic care plan model along with the essential concepts of chronic disease management and Care Planning. Ultimately in the end our model will serve as a merge point of (a) chronic disease management and (b) Care Planning because it present all the essential components of these on a single platform. We claim this merging platform as our Generic Care Plan Model. The generic care plan model is a result of the knowledge abstraction process.

CONCLUSION: Generic Care Plan Model is developed as a result of two research activities namely (a) knowledge abstraction and (b) iterations. Longitudinal nature of chronic disease management features several important aspects that need to be considered during the care delivery process. For proper care of the chronic illnesses, it is necessary to have proper care planning for treatment with regular follow up procedures.

The researcher can be reached at:

July 1, 2016

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