IMPROVING THE MANAGEMENT OF LONG TERM CONDITIONS

AIMS

1 For me to share with you– What we’ve learned so far– What we don’t know yet

2 Your help to develop an improvement tool to support NHS implementation

I believe that improving the management of people with long term conditions through a systematic approach to care will:

Optimise patients’ quality of life Improve patient & professional satisfaction Reduce unplanned admissions and LOS in

hospital (target!) Encourage secondary to primary care shift

of resources Reduce prescribing budgets

INCIDENCE OF CHRONIC DISEASE

17.5m people may be living with a chronic disease

By 2030 incidence of chronic disease in the 65+ will have doubled

80% of GP consultations relate to chronic disease

Prescriptions increase with co-morbidities

05

101520253035404550

Average no. of

prescriptions

0 1 2 3 4 5+

No. of chronic diseases

Prescriptions

SelfManagement

Level 170-80% of a

CDM pop

POPULATION-WIDE PREVENTION

Level 2High riskpatients

DiseaseManagement

Level 3Highlycomplexpatients

CaseMgt

LTC Management

CASTLEFIELDS HEALTH CENTRE (UK)

15% reduction in unplanned admissions31% reduction in hospital LOS (6.2 to 4.3)Total hospital bed days fell by 41%Significant savingsBetter patient experienceImproved integration + more appropriate referrals

VETERANS’ ADMINISTRATION (USA)

35% reduction urgent care visit rate

50% reduction hospital bed days

EVERCARE (USA)

50% reduction unplanned admissions without detriment to health

Significant reductions in medications

97% family and carer satisfaction

High physician satisfaction

NHS-ADAPTED EVERCARE

3% of target population = 30% unplanned admissions for that age group

many admissions avoidable (urinary tract infection, dehydration)

55-87% high risk population not accessing DNs & Social Services

polypharmacy

THE TRANSFORMATION

Care is Proactive

Care delivered by a health care team

Care integrated across time, place and conditions

Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology

Self-management support a responsibility and integral part of the delivery system

Chronic Care Model

Source: KPCMI [21]

Complete Forms

Deal withAcute Attackof Disease

Counsel re: Lifestyle ChangesReview

LabsAccess

Social/Other Services

Reassure

Diagnose

General Referral

Review/Adjust Rx and Tx Routine

Preventive Care

Modify and/or Negotiate Care

Plans

Review History

Review Care Plan

Talk with Family

Reinforce Positive Health

Behaviours

Traditional Model

SICKNESS CARE MODEL (Current Approach - Physician Centric)

Consultation 10 minutes

• Acute system

• Treat the episode

• Don’t make the connections

And . . .

. . . .the patient is more likely to be admitted again

COMPONENTS OF EFFECTIVE CDM (1)

Population management & risk stratification - (informing decisions)

Effective registers and integrated records

Evidence–based “care pathways”

Disease management and care co-ordination

COMPONENTS OF EFFECTIVE CDM (2)

Self care/self management - with information and support

Active management of at-risk patients

Primary/secondary/social care co-ordination

SO HOW DO WE MAKE THIS PARADIGM SHIFT?

Start with better data extraction and information analysis to inform decisions

Implement case management for patients with highest burdens of disease

Implement NSFs for managing diseases and consider care co-ordination

Support self management and self care

Measure progress and achievement; and adjust process when necessary

WHAT WE DON’T KNOW YET?

• When will incentives be aligned?• Policy not yet fully articulated.• Care co-ordination – how do we do?• Impact on workforce – particularly

nursing?• What is our evidence for taking

forward?• What practice/ models work and where

is it?

IMPROVING THE MANAGEMENT OF LONG TERM CONDITIONS

AIMS

1 For me to share with you– What we’ve learned so far– What we don’t know yet

2 Your help to develop an improvement tool to support NHS implementation

BUT NHS MUST START TO IMPLEMENT!

Can we work together to populate an implementation tool by

harvesting what we already know?

Improving the Management of Long-Term Conditions

Step 1/Informed DecisionMaking

Step 2/Case Managing Patients with Highest Burdens of Disease inCommunity

Step 3/CoordinatingCare for People With Chronic Disease

Step 4/Encouraging Patients to Become Confident and InformedAbout ManagingTheir own Condition

Step 5/MeasuringAchievement

Step 1/ Informed Decision-Making

Key Activities:

1.1 Identify and analyse population with LTCs

1.2 Plan services to support and care for them

1.3 Compare with current service provision

1.4 Commission services to support need and plug gaps

Step 2/ Case-Managing Patients with Highest Burdens of Disease in Community

Key Activities:2.1 Identify patients who are your frequent unplanned

admissions2.2 Combine their acute history with GP practices & Social

Care’s2.3 Carry out clinical & social assessment in their home &

agree Care Plan with them2.4 Check & manage their medicines2.5 Ensure delivery of Care Plan through multi-disciplinary

team in primary care; and by orchestrating the care across secondary and social care boundaries.

Step 3/ Coordinating Care for People with Chronic Disease

Key Activities:

3.1 Implement NSFs

3.2 Implement proactive, systematic review, recall & reassessment processes

3.3 Provide “holistic” care for patients with co-morbidity

3.4 Ensure seamless delivery of care pathway across organisational boundaries.

Step 4/ Encouraging Patients to Become Confident and informed about Managing

Their own ConditionKey Activities:4.1 Provide patients with information about their

condition(s), how to access services in NHS and social care, including OOHs

4.2 Refer patient to Expert Patient Programme4.3 Signpost patient toward other support provided by

voluntary and community sector, local authority, and others

4.4 Prescribe effective (combinations of) medicines4.5 Provide tools to support home monitoring and testing4.6 Engage patient throughout care pathway on improving

self-management

Step 5/ Measuring Achievement

Key Activities:5.1 Assess baseline5.2 Monitor progress5.3 Adjust processes if necessary5.4 Identify interventions that make a difference,5.5 Gather effective practice5.6 Extract learning and share widely

Populating the Process Model

Name/ Step x 5

Question

LearningLearning Learning

Learning

QuestionQuestion

Question

1. Review the Steps2. You are only allowed 4

post-its of either colour3. Write down your

Learnings/ Questions IN CAPITALS

4. Name your post-it5. Put your post-its on the

correct whiteboards6. Be prepared to explain

your post-it question or learning in the review stage

7. Have a look at other learnings and questions on other steps

Populating the Model-marking your contributions for the review stage

Name/ Step x

QUESTION

LEARNING

4.1

4.1

Jane B

Mike A

Populating the Model-matching learnings to questions

Name/ Step x

Question

LearningLearning Learning

Learning

QuestionQuestion

Question ?New

Question

Review

1 Common, Special, Missing2 New work and new ideas: building the new agenda

around LTCs3 Validity of 5-stage Generic Model4 Next steps –sharing prototype with you and building new

practice framework around LTCs5 Thank you!