Track 4: Sostenibilidad de los sistemas sanitarios 4.2. Gestión de la cronicidad

1. Chronic Care Management
MIHealth Congress
24.05.2012
Berlin Stroke Alliance
(BSA)
Isabelle M. Missala
UNIVERSITÄTSMEDIZIN BERLIN 1

2. Charité – Universitätsmedizin Berlin
Campus Buch
Campus
Virchow-Klinikum
Campus
Charité Mitte
Campus
Benjamin Franklin
UNIVERSITÄTSMEDIZIN BERLIN 2

3. Agenda
 WHO Definition „Chronic Diseases“
 Key Facts
 Cardiovascular diseases
STROKE
 Stroke Care Management: Berlin Stroke Alliance (BSA)
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4. Definition WHO
Chronic diseases (CDs) are diseases of long duration and
generally slow progression
are by far the leading cause of mortality in the world,
representing 63% of all deaths
Out of the 36 million people who died from chronic disease in
2008
• 9 million were < 60 years
• 90% of these premature deaths occurred in low- and
middle-income countries
Examples of chronic diseases:
Coronary heart disease, stroke, cancer, chronic respiratory
diseases and diabetes
UNIVERSITÄTSMEDIZIN BERLIN http://www.who.int/topics/chronic_diseases 4

5. Key Facts Cardiovascular Diseases
CVD
• CVDs are the number one cause of death globally:
 More people die annually from CVDs than from any other cause.
• An estimated 17.3 million people died from CVDs in 2008, representing
30% of all global deaths. Of these deaths, an estimated 7.3 million were
due to coronary heart disease and 6.2 million were due to stroke.
• Low- and middle-income countries are disproportionally affected:
over 80% of CVD deaths take place in low- and middle-income countries
and occur almost equally in men and women.
• By 2030, almost 23.6 million people will die from CVDs, mainly from
heart disease and stroke. These are projected to remain the single leading
causes of death.
UNIVERSITÄTSMEDIZIN BERLIN WHO Fact sheet N°317 September 2011 5

6. CVD Disease Clinical Pictures
•
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7. Cardiovascular diseases –
heterogenous group of disorder
• Cardiovascular diseases (CVDs) are a group of disorders of the
heart and blood vessels and include:
• coronary heart disease – disease of the blood vessels supplying
the heart muscle
• cerebrovascular disease - disease of the blood vessels
supplying the brain
• peripheral arterial disease – disease of blood vessels supplying
the arms and legs
• rheumatic heart disease – damage to the heart muscle and heart
valves from rheumatic fever, caused by streptococcal bacteria
• congenital heart disease - malformations of heart structure existing
at birth
• deep vein thrombosis and pulmonary embolism – blood clots in the
leg veins, which can dislodge and move to the heart and lungs.
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8. Stroke Epidemiology Germany
Men Women Total
First strokes 88 000 108 000 196 000
Recurrent 30 000 36 000 66 000
strokes
Total 118 000 144 000 262 000
*based on data of the Erlangen Stroke register (2008)
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9. Impact of Stroke
• Third common cause of death (8%)
• Cause of death 63.000/a (2008), regression!
• Main cause of severe disability of the adult
• Age of predisposition:
60.-70. life year, half of the stroke patients are more than 73
years old
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10. The Berlin Stroke
Alliance (BSA)
2008–2012

11. Aims
• The BSA is an association of caregivers of stroke or TIA
patients in Berlin and Brandenburg. The BSA was
founded on the 26th of June 2008.
• The purpose of the BSA is to:
a. improve the care and outcome of patients with stroke or
TIA (transistory ischemic attack)
b. promote patient-based research projects
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12. The BSA network
• 48 full members
• 4 associate members
• in the field of:
• Acute care,
• Rehabilitation
care,
• Aftercare.
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13. Project fields of the BSA
Education
&Training
Research Coun
selling
Quality
management
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14. Working Areas
I) Improvement of Counselling of stroke patients and their relatives.
II) Improvement of Education and Training in the field of „Stroke“ for
various occupational groups involved in stroke - treatment.
III) Coordination of Data Collection in the field of „stroke “.
IV) Conduction of high-quality patient - based trials.
V) Development of a coordinated chain of health care providers for
stroke patients in Berlin (and Brandenburg).
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15. Working Groups
I) AG Social Services
II) AG Education and Training
III) AG Transfer Processes
IV) AG Core Data Set Rehabilitation
V) AG Aftercare
VI) AG Longterm Management
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16. AG Social Services
Aims:
Multidisciplinary Transfer Sheet at the interface between
Rehabilitation > Aftercare
Highlights:
Transfer Sheet, existing rules of procedures and prove of
data protection of the transfer sheet
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17. AG Education and Training
Aims:
Development of a stroke specific educational program carried out by the
BSA members
Highlights:
4 established Curricula of the working group:
• Medical Curriculum (Ø 16 participant)
• Curriculum of healthcare professionals (Ø 40 participant)
• Curriculum skills (28 participant)
• Information meeting for patients and their relatives (Ø 18 participant)
• increasing number of participant
• evaluation „good“ and „very good“
• Basic lesson „Stroke Nursing Expert“ for Nurses starts in 2012
• –
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18. AG Transfer Processes
Aims:
• Development of the Transfer form „Application of early
rehabilitation and application for covering the costs “
• IT-Support of Transfer (Webportal) between acute and
rehabilitation care clinics.
Highlights:
• Form was developed and voted.
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19. AG Core Data Set Rehabilitation
Aims:
Development of quality indicator (QIs) of post-stroke
rehabilitation
Highlights:
• Definition of a final indicator set of 18 QIs
• Implementation 2012
UNIVERSITÄTSMEDIZIN BERLIN 19

20. AG Aftercare
Aims:
Improvement of outpatient care (after inpatient care)
Highlights:
• Information packet for patients and relatives (hand-over
to all BSA-members)
• Implementation of a web-based database „Stroke-Pilot“
of stroke-care and additional support offers
• Designation of a stroke-representative in all BSA-
Member institutions
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21. AG Longterm - Management
Aims:
• Improved transparency and network of structure elements of
outpatient management
• Cooperation with stroke-specific quality circle programs
• Development of a scientific-based concept of improvement of stroke
patients longterm management in an outpatient setting
• Early involvement of health insurrances
Pilot-project Concept:
• „University Outpatient Department of Management of stroke –
longterm - results“
• Promote networking of existing structures, evaluate ongoing
activities
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22. Servicepoint Stroke
• Central Consulting Center for
Stroke Patients and Relatives
• Internet: www.schlaganfall-allianz.de
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23. Servicepoint Stroke
Servicepoint Stroke
Consulting by
Information Stroke Support in care Information
and Counseller managament Meetings
Counselling and BSA system
partners
Target Group:
Stroke patients of all ages with and without need for assistance,
relatives and those interested in the topic
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24. Better Understanding,
More effective treatment.
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25. Thanks for your Attention
For more information please contact:
Isabelle.missala@charite.de
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