Health Promotion International Advance Access originally published online on September 22, 2008
Health Promotion International 2008 23(4):372-379; doi:10.1093/heapro/dan030
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PERSPECTIVES |
Transferring disease management and health promotion programs to other countries: critical success factors
1UK Pfizer Health Solutions, Walton-on-the-Hill, Surrey, UK 2European Pfizer Health Solutions, UK 3Pfizer Health Solutions, Santa Monica, USA 4Health Services Management Centre, University of Birmingham, Birmingham, UK
* Corresponding author. E-mail: Pejman.Azarmina{at}pfizer.com
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SUMMARY |
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Governments and health service providers around the world are under pressure to improve health outcomes while containing rising healthcare costs. In response to such challenges, many regions have implemented services that have been successful in other countries—but ‘importing’ initiatives has many challenges. This article summarizes factors found to be critical to the success of adapting a US disease management and health promotion programme for use in Italy and the UK. Using three illustrative case studies, it describes how in each region the programme needed to adapt (i) the form and content of the disease management service, (ii) the involvement and integration with local clinicians and services and (iii) the evaluation of programme outcomes. We argue that it is important to implement evidence-based practice by learning lessons from other countries and service initiatives, but that it is equally important to take into consideration the ‘3Ps’ that are critical for successful service implementation: payers, practitioners and patients.
Key words: disease management; health promotion; telehealth; dissemination of innovation
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INTRODUCTION |
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More than 35 million people worldwide will die every year from chronic diseases, such as diabetes, heart failure and coronary heart disease (WHO, 2005
). Healthcare systems cannot cope with the increasing incidence and cost of chronic diseases. Fifty to 80% of the health budget across low, medium and high income countries is spent on chronic diseases (Suhrcke et al., 2006). Without intervention, this will continue to rise as long as risk factors such as tobacco use, unhealthy diet and lack of physical activity remain prevalent (Rabin et al., 2007).
Many interventions have been implemented to reduce the social, health and financial impacts of chronic disease. However, when applied in isolation, these interventions may have limited long-term impact (Singh, 2005). ‘Disease management’ is a systematic approach for co-ordinating healthcare interventions and communications at individual, organizational, regional or national level. Evidence suggests that planned proactive care can lead to a better quality of life and improved health outcomes for people with long-term conditions (Ouwens et al., 2005; WHO, 2006). There is also evidence that preventive approaches that focus on health promotion are an essential component of successful disease management programmes (WHO, 2004).
Around the world, healthcare organizations are responding to the challenge of chronic disease by trialling disease management approaches that have been successful in other countries. However there are many issues with transferring health services or approaches from one country to another, including the need to account for diverse social, economic, policy and practical factors. Many studies have suggested that it is not possible to transfer programmes from one country to another without accounting for cultural and social variations (HEN, 2003; Hoijtink and Rascher, 2005).
This article describes the key success factors for ‘rolling out’ disease management programmes to different regions, based on detailed evaluation of three ‘disease management’ programmes in Europe that adapted a US model. The programmes used qualitative and quantitative methods to evaluate their individual successes and a descriptive root cause analysis to draw out the critical success factors in making adaptations for the local context (Azarmina et al., 2007b).
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PROGRAMME OVERVIEW |
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There is strong evidence that education, support and empowerment lead to better self care, which in turn improves outcomes and reduces the use of hospital services (Lorig et al., 2001
; Ellis et al., 2004). However, self management alone cannot sustain improved outcomes. Components such as decision support systems and follow-up care are also required (Richardson et al., 2005).
To address these needs, proactive ‘disease management’ services that focus on prevention and mitigation have been developed to inform and motivate people with chronic conditions and to help coordinate care from various health providers. Pfizer Health Solutions developed a telephone-based disease management system that has been successful in many parts of the US, implemented by various providers and Medicaid and Medicare plans (Pfizer Health Solutions, 2008). The programme involves motivational coaching and care co-ordination using regular telephone support from nurse ‘Care Managers’ who use a computerized record keeping and decision support system that draws on localized care pathways and evidence-based guidelines. The programme is based on the principle that motivating people will lead to better health behaviours, thus improving clinical outcomes, which in turn will reduce the use of hospital services.
The programme uses the trans-theoretical ‘Stages of Change’ model to help assess an individual's readiness to make a behavioural change (Prochaska and Velicer, 1997). This model hypothesizes that people go through a series of stages in achieving behavioural change. Depending on their stage of change, Care Managers use different techniques to help people feel confident making decisions about their care and to encourage people to take action to keep themselves healthy, slow the deterioration of their condition and improve their quality of life. The frequency of telephone contacts is based on individual need. As a minimum, Care Managers aim to contact patients monthly.
A number of systematic reviews have suggested that proactive telephone support of this nature can improve people's quality of life, reduce use of other health services and improve their health status (Barlow et al., 2007). For example, randomized trials have found that nurse-led telephone disease management can reduce the probability of hospitalization for people with heart failure by up to 45%, halve hospital costs and improve quality of life within a 6–12 month period (Dunagan et al., 2005; Riegel et al., 2002).
However, while proactive telephone support is established in the USA (Piette, 2000), it has not always been successful when transferred to other countries (Stroetmann et al., 2003). We analysed the factors that would help to roll out a successful telephone-based disease management programme from the USA in Italy and two parts of the UK. Brief details about each of these three case studies are provided below, before drawing out the key success factors in adapting the programmes for different contexts. All of the case studies used nurse Care Managers to provide regular one to one coaching, customized care plans, education materials and service coordination between providers.
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IMPLEMENTATION IN LONDON, UK |
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TOPSUMMARYINTRODUCTIONPROGRAMME OVERVIEWIMPLEMENTATION IN LONDON, UKIMPLEMENTATION IN BIRMINGHAM, UKIMPLEMENTATION IN PUGLIA, ITALYKEY SUCCESS FACTORSCONCLUSIONFUNDINGREFERENCES |
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Managing long-term conditions is a high priority for England's National Health Service (NHS). There are National Service Frameworks that establish evidence-based standards of care for people with chronic conditions, incentives for reaching clinical targets in primary care, changes to how hospital activity is funded and self management group education programmes. In this context, between 2003 and 2005 England's Department of Health collaborated with a public sector organization responsible for purchasing and managing all healthcare in a London region (primary care trust) and a private sector partner (Pfizer Health Solutions) to form ‘TeamHealth’ which adapted a US model into an NHS setting.
TeamHealth included a randomized controlled trial with 740 people (589 interventions and 151 controls) with coronary heart disease, diabetes or heart failure. People were selected by their GPs (family doctors) and invited to participate in the programme. On average, people received 1 year of disease management before final outcomes were assessed. The trial concluded that it was feasible for a public–private partnership to implement a telephone-based disease management service that achieved a high degree of patient satisfaction and had a positive impact on psychosocial and health-related behaviours. Service users also developed strong relationships with new healthcare providers (Azarmina et al., 2007b).
The key learning points included the importance of ensuring that there is a common language about and understanding of disease management among all partners, ensuring rigorous selection and training of Care Managers particularly in health-related behaviour change, the need to integrate with local clinicians and the importance of high quality software hosting when relying on computerized decision support tools.
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IMPLEMENTATION IN BIRMINGHAM, UK |
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TOPSUMMARYINTRODUCTIONPROGRAMME OVERVIEWIMPLEMENTATION IN LONDON, UKIMPLEMENTATION IN BIRMINGHAM, UKIMPLEMENTATION IN PUGLIA, ITALYKEY SUCCESS FACTORSCONCLUSIONFUNDINGREFERENCES |
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Building on the successes of TeamHealth, another similar public–private partnership was tested in Birmingham, UK between 2006 and 2007. Birmingham OwnHealth® was a partnership between two public sector primary care trusts (payers), NHS Direct (a publicly funded nurse-led telephone service) and a private sector partner (Pfizer Health Solutions). In this service, 12 NHS Direct ‘call centre’ nurses who had been responding to incoming telephone enquiries were trained to provide proactive outbound calls.
Thousand one hundred and eight people were enrolled over a 13 month period. Participants ranged from 18 to 98 years, with an average age of 66. About 12% of participants were from Asian or Black ethnic backgrounds. Care Managers telephoned people an average of once every 4 weeks, with calls lasting about 12 minutes on average. The service included bi-lingual Care Managers to enable inclusion of the diverse population served.
An observational pre- and post-test evaluation found that people who participated in Birmingham OwnHealth® thought that the service was accessible and easy to use and felt more confident in their ability to self manage their conditions. Participants also had statistically significant improvements in their willingness to make behaviour modifications and showed measurable changes in their diet, exercise and smoking habits. There was improved cholesterol, blood glucose and blood pressure control and improved concordance with medication regimens. Participants also reported fewer symptoms overall.
For example, upon enrolment in the programme, about 4 out of 10 people were at the recommended stage of change in their dietary habits. Eight months later, 70% of people were at the desired stage of change, 8 out of 10 were following a dietary plan, and there had been a significant reduction in self-reported salt consumption (Azarmina et al., 2007a).
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IMPLEMENTATION IN PUGLIA, ITALY |
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TOPSUMMARYINTRODUCTIONPROGRAMME OVERVIEWIMPLEMENTATION IN LONDON, UKIMPLEMENTATION IN BIRMINGHAM, UKIMPLEMENTATION IN PUGLIA, ITALYKEY SUCCESS FACTORSCONCLUSIONFUNDINGREFERENCES |
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This system of disease management has also been adapted for use in Italy. The programme, Project Leonardo, was a public–private partnership between the regional government of Puglia and two private sector organizations (Pfizer Italia and Pfizer Health Solutions). Like the other two case studies above, Project Leonardo provided proactive identification and treatment of people with diabetes, heart failure and cardiovascular disease.
Project Leonardo used a team-based approach, with nurse Care Managers, physicians and specialists working together as ‘partners’ with enrolled patients. Thirty Care Managers were employed by the local health authority and worked in GP practices—they saw service users face to face and in their homes, rather than relying solely on telephone contact. GPs received financial incentives for meeting enrolment and assessment targets and clinical outcome indicators.
An 18 month observational pre- and post-test evaluation of 1153 patients enrolled between 2006 and 2007 found significant improvements in SF-12 Physical and Mental Health scores (p < 0.0001) and self-reported medication adherence (p < 0.0001); 66% reported improved general health; 59% reported improved functional ability; significant improvements in the number of patients meeting blood pressure goals (p < 0.001) and total cholesterol goals (p < 0.001); 60% reported an improved relationship with their GP; and 76% of care plans were developed jointly by Care Managers and GPs.
To adapt the disease management model from the US to Italy, cultural, linguistic and logistical changes were necessary. Given the value and importance of face-to-face communication in southern Italy, Care Managers were placed in GP offices rather than solely using a telephone-based approach. This enabled Care Managers to have face-to-face contact with service users and directly coordinate information and services between GPs, specialists and patients.
The project necessitated a significant change in the local health care delivery model. GPs were not used to having a nurse or health assistant in their office so this required extra integration efforts. Lastly, educational, training and clinical guideline materials needed to be adapted linguistically and culturally to meet local norms and practices.
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KEY SUCCESS FACTORS |
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These three case studies provide evidence about factors that are critical when importing successful services to new regions. The evaluation teams found that in each area it was essential to involve and transform a range of factors to ensure success. The ‘3Ps’ of successful transformation were payers, practitioners and participants (Figure 1). This section outlines the transformations that are needed at each level.
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Payers
These three evaluations found that in order to import components of a US programme to Europe, it was important to make adaptations at the level of policy and payers (service commissioners). These adaptations included partnerships between the public and private sectors, a focus on preventive care, outcomes-based commissioning and engagement of senior managers and clinicians.
While the US focuses on a mix of publicly and privately run models, in Europe the central role of the government as payer necessitated and benefited from partnerships between the public and private sphere. These partnerships allowed access to a wide range of skills and experience from both sectors as well as the decision support tools of industry and the patient databases and providers of the public sector.
To support these partnerships, it was important to link the programmes to shifts from secondary care to primary care and health promotion. Regions around the world are acknowledging the importance of health promotion and proactive preventive support, as well as a reactive ‘treatment-based’ model (Singh, 2007). In both the UK and Italy, the success of the disease management programme was related to linking potential outcomes to the policy focus on prevention and the payers’ focus on primary care. In all cases, there was strong political and high-level managerial support for the programmes. For instance in Italy, Project Leonardo was sponsored by the regional government and in London TeamHealth was sponsored by the Department of Health.
Another aspect of the payer context is the need to engage senior managers and clinicians in the development and implementation process. For example, in the London TeamHealth initiative, this involved establishing working relationships and governance processes to ensure that the partnership was open and transparent. A Project Board made up of all stakeholders and partners had overall responsibility, with working groups reporting to the Board on a routine basis. An Evaluation Steering Committee was established, including an external statistician and clinician. In addition, an independent group of clinicians met on a regular basis to review and approve and the clinical guidelines and patient materials used.
One way to engage clinicians is through GP performance payments, tied not just to participation but specifically outcomes. In Project Leonardo in Italy, GPs gained financial rewards for both recruitment of patients and demonstrating positive outcomes. Although this may be controversial, it was found to be an important factor in securing GP union participation in the project and served as an additional and ongoing motivation for GP engagement in the effort. From a broader payer perspective, payment based on outcomes rather than activity levels or other proxy indicators of success ensures that programmes which have a direct and measurable effect on outcomes are likely to achieve longevity. In all three case studies, the programme team encouraged commissioners to purchase ongoing disease management services based on their outcomes, rather than the number of people they enrolled or the number of calls made. This may be a significant shift in the way payers commission services.
For this reason, rigorous evaluation was an important adaptation of the programme for payers. All three of the case studies considered, at the beginning of the programme, the outcomes to be measured and upon which the success of disease management would be assessed. The payers recognized the importance of evaluation early on so they commissioned an evaluation from the outset, thus allowing baseline data to be collected and a robust yet practical evaluation strategy to be developed.
The evaluations involved a wide range of measures and developed an approach to measuring outcomes beyond simple activity figures. These methods also helped to improve performance management more generally. For example, the evaluation of Birmingham OwnHealth® developed a model to examine the organizational, satisfaction, clinical, activity and resource implications of interventions (OSCAR, using the first letter of each outcome variable). The payers are now using this as a model for assessing other commissioned services throughout the region.
In short, in order for programmes to be transferred successfully from one region to another, there needs to be high level engagement, a focus on making adaptations for local needs and a commitment to quality improvement through monitoring and learning.
Practitioners
Transformations are also required at the level of practitioners or providers. Our evaluations found that in order to be successful, providers need to adapt to providing more integrated care and assess their outcomes rigorously. They also need to consider developing new workforce roles and focus on empowering service users.
A key success factor in of all the programmes was a focus on linking different providers to ensure more seamless and integrated care. Introducing new services highlights the need for better management integration, especially when service users need to be identified, targeted and followed up with continuously. The requirements of a proactive service differ from those of a reactive service. Care Managers aimed to co-ordinate primary care and specialist health care, as well as signposting to social care and voluntary sector services. Rather than working in silos, successful providers saw themselves as part of a care pathway, helping service users on their journey towards self care and empowerment.
In Italy, Project Leonardo helped to transform the local health economy and the roles of GPs and nurses. GPs were not used to working alongside nurses in their practices so the programme focused on demonstrating the usefulness of partnerships between providers. GPs found that nurse Care Managers could help them achieve their targets and improve patient care.
Providers also needed to adapt to an outcomes-based culture because they needed to develop methods to demonstrate quality and outcomes. A key component of this was the consistent use of the decision support software, which allowed Care Managers to keep detailed records of outcomes during every call. The guidance and motivation that Care Managers provided to patients was based on this evidence-based decision support tool, which was refined to meet local needs, including inserting local guidelines agreed with clinicians.
This use of innovative technologies was a key success factor, as was adapting the delivery method to meet the local context. In the original US programmes, telephone support alone was used to motivate and engage with participants. The TeamHealth and Birmingham OwnHealth® evaluations suggested that this telephone-based approach was also feasible in the UK but in Puglia, Italy such an approach was deemed culturally inappropriate so a model which used face-to-face contact was implemented. The other core aspects of the programme remained the same, but the delivery method was adapted to account for local norms.
Another example of provider adaptations for the local context is the bilingual service offered by Birmingham OwnHealth®. Due to the diverse Asian community in the Birmingham area, the service was advertised as bilingual and participants had the option of working with a Care Manager who spoke Urdu and Punjabi.
Participants
Finally, the evaluations of these three programmes found that transformations were required among participants or patients, including an acceptance of the importance of self care, health literacy and adoption of new ways to receive care.
Health systems and policies are moving from a reactive ‘treatment-focused’ approach towards more preventive and empowerment models (WHO, 2006), but the success of such initiatives rests partly on acceptance of the importance of self care by service users. Disease management approaches, whether using telecare, face-to-face appointments or group education, are focusing on motivating and educating people about their role in keeping themselves well. To maximize success, all three of the disease management programmes evaluated focused on engaging with participants, seeing them as partners in care and encouraging them to take responsibility for their own health and wellbeing. Without buy-in from participants, success would be limited and short-lived.
Participants also needed to adapt to new methods of receiving care. In the UK studies, participants tested a telephone-based approach, supported by posted materials and emails. The evaluations found that some people were reluctant at first to discuss health issues over the telephone with a nurse that they had not met, but over time they accepted this method and grew to enjoy and look forward to calls. Some suggested that telephone support provided unique benefits over face-to-face appointments.
The fact is you are talking to somebody who is on the other end of a telephone who you can pass in the street and they will not know you and you will not know them and therefore you can share confidences without feeling exposed by it. I was recently asked, as a diabetic, what effect it had had on my sex life and I was quite able to discuss that over the telephone, not just accurately but light—heartedly, which to a lot of people in a face-to-face situation would be a test. The fact that it is not face-to-face takes the threat element out of it. (Birmingham OwnHealth® participant)Similarly in Italy, participants adapted to consulting with nurses in the GP clinic and to having care plans developed in partnership with both Care Managers and GPs.
Participants in all three programmes also adapted to using care plans, educational booklets and other resources provided by the Care Managers to improve their health literacy. All participants were provided with booklets to record their blood pressure, cholesterol levels, weight and other clinical indicators after each visit with their GP or other professionals. These ‘patient held records’ helped participants provide Care Managers with accurate updates about their progress and also encouraged them to learn more about each measurement and what it meant about their health.
The lesson learned from these three programmes is that in order to improve health outcomes, it is essential that interventions have buy-in from participants. While this buy-in may not be immediate, it is a critical factor that programme developers must consider when transferring initiatives from other contexts.
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CONCLUSION |
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Sixty percent of deaths around the world are due to long-term conditions, but the World Health Organization suggests that these deaths may be largely preventable. If the major risk factors for chronic disease were eliminated, 80% of heart disease, stroke and type 2 diabetes would be prevented (WHO, 2005
).
While there is no ‘magic solution’ to prevention, disease management programmes which co-ordinate care and focus on health promotion and motivating people to self care have been found to significantly improve people's health and reduce the use of hospital services. However, it is not possible to merely ‘import’ successful programmes from one country or region to another. A number of reviews and randomized trials have demonstrated that interventions that are successful in one context do not necessarily transfer easily to another (Ouwens et al., 2005; Richardson et al., 2005).
Evaluations of three adaptations of a US disease management model found that transformations at three levels are essential. The ‘3Ps’ of successful programmes involve payers, practitioners and participants. There are clear lessons for practitioners and policy makers when implementing service developments and trialling new approaches (see Box 1).
| Box 1: Key lessons for policy and practice Payer level Promote effective working partnerships Work to integrate across multiple settings Secure support from stakeholders and senior managers Obtain political buy-ins Secure clinical engagement and buy-in Include outcomes focused payments Tackle underlying determinants of ill health Focus on evaluation from the outset Recognize that substantial investment is needed Provider level Establish a dedicated project management team Customize clinical content to local standards Adapt service delivery methods to local needs Consider language and cultural needs Provide evidence-based care Adopt new roles and technologies Participant level Empower individuals, families and communities Motivate people to self care Accept different delivery methods Use new technologies
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In summary, an analysis of success factors suggests that in order to roll out disease management interventions, both the model of care and the healthcare system must be altered. The case studies reinforce theoretical material and other evidence which suggest that it is not enough to focus on innovative service delivery methods (Catford, 2007; Epping-Jordan et al., 2005). Instead, policy makers and practitioners must focus on adapting components of payers, providers and participants within healthcare systems in order to facilitate sustainable and successful change.
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FUNDING |
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This symposium was co-funded by Pfizer Inc. and Pfizer Ltd.
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ACKNOWLEDGEMENTS |
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This paper was presented as a symposium at the 19th IUHPE World Conference on Health Promotion and Education in Vancouver, Canada. The authors wish to thank Dr Jack T Watters for his generous support and John Procter, Adrian Reedman, Andrew Donald, Gerry Taylor, Andrea Musilli and Dr Ambrogio Aquilino for their contributions to the symposium and this paper.
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TOPSUMMARYINTRODUCTIONPROGRAMME OVERVIEWIMPLEMENTATION IN LONDON, UKIMPLEMENTATION IN BIRMINGHAM, UKIMPLEMENTATION IN PUGLIA, ITALYKEY SUCCESS FACTORSCONCLUSIONFUNDINGREFERENCES |
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