Transcript Presentation 2 - Northern Deanery

Frequent Attenders
A Family Systemic approach
Dr Venetia Young
Lakes Medical Practice
Penrith, Cumbria
Bishopyards Surgery
• Small market town – 20,000
• 5500 patients 5 doctors (3WTE) 2 nurses, pharmacist
• Consultations with GP in surgery 5 or more Jan –
March 2007
• 163 patients 1025 appts 3% of list
• 25% ADT
• Top 50 33% on ADT
• One child
• High proprortion middle aged women
Audit
• Top5 – 3 major Mental Illness all in contact with
CMHT, 1 severe eating disorder, 1 complex
social problem
• 10 depression anxiety – 8 on waiting list for
PCMHT
• 2 severe illness - both died
• 7 straightforward physical illness
• 26 multiple symptoms
Sheffield study
•
•
•
•
•
•
Waller and Hodgkin 2000
9 practices
1.3% of list 8.3% consultations (20 pa)
3.6% generated 17.6% consultations (15pa)
42% on ADT
1/3 repeated the behaviour the next year
How was this managed?
•
•
•
•
•
•
Discussed with GPs
!0 patients in referral process with PCMHT
CMHT contacted re top 3
ED admitted
Social problem family – regular appts
Remaining ones noted and VY worked with 15:
genogram, ICE, stress cycle, hyperventilation, HADS
and ADT where appropriate
• 3 patients offered regular routine FU
continued
• Training all staff on Stress management and Health
Related Anxiety
• 2 GPs, HCA and pharmacist on Positive Mental
Training
• Regular meetings with HV and school nurse
• Better focus with PCMH team
• Change to green slip for appointments
• Cultural shift to active management
• Less use of locums
One year on
• 44 patients
• One consulted 10 times – SMI plus new
diagnosis of pulmonary fibrosis
• Less than 1% list
• Even age distribution except 20-40
• More female
• Saving 200 appts over 3 months
Some cases
• Margaret 60 divorced
• Headache, dyspepsia, migraine hypertension obesity, neck ache,
back ache
•
•
•
•
•
•
•
Genogram
Women who love too much
Self-help leaflets
Breathing and relaxation techniques
Solution focussed questioning
90 minutes over 6 appts
2012 – has not been a frequent attender since despite hip
surgery, DVT
Patient comments
• Rachel – pleased to have diagnosis of ME and
not to have to pester the doctors any more
• Jo 68 – phoning Drs sign of being unwell and
needed CMHT
• Liz 32 – finally agreed for referral for
psychotherapy
What are the patients needs?
•
•
•
•
•
Have the workings of their bodies explained to them.
Distress – relationships, work, school money housing
Depression – referral and Adt
Anxiety disorders especially HRA need recognition
Major MI treated and managed better between team
and surgery
• Good quality self-help literature including books
• Good quality referrals
Skill implications for whole team
•
•
•
•
•
•
•
•
•
•
Active management not reactive
Good assessment
Eliciting patient’s backgrounds
Explaining stress and its effect on body
Hyperventilation
Managing affect in consultation and on the phone
Therapeutic skills for watchful waiting
Finding the Frequent attender
Noticing the medication abuser
Using self help materials to empower the patient
More advanced consultation skills
•
•
•
•
•
•
•
•
BATHE
SFBT
CBT
Hypnotherapy
NLP
EFT
Human Givens – enhanced CBT
Systemic (Family Therapy)
Primary care team and the wider
community
• Community resources: where there are gaps
patients will present in the surgery: young
Mums, middle aged women, elderly
• Mental health organisations
• Social Care organisations
• Third sector
Further update
•
•
•
•
•
•
•
•
•
•
•
Two practices have merged with different FA problems
GP trainees and medical students given data to audit
Monthly PCMH meeting: school nurse, HV And CMHT – safeguarding
MIND and PCMHT doing condition management programme
Menopause evening
COPD afternoon
Training for all staff on personality disorder, recognising abuse and domestic
violence
GP and nurse practitioner consultation skills training
Locality practices all doing FA audit and being surprised!
Ideas in pipeline are a group for women 45-65 who are FAs, pain
management group and mindfulness group
Consideration of employing MH practitioner rather than GP – a missing tier
in service delivery
References
• Waller and Hodgkin: General practice -demanding work 2002
Radcliffe
• Asen Tomson and Young: ‘10 minutes for the family’ 2004
Routledge
• Larivara 1996 ‘Developing a Family Systems approach to rural
healthcare: dealing with the heavy user problem’ Families,
Systems and Health 1996 14:291-302
• Kroenke and Mangelsdorf 1989 American Journal of Medicine
86 262-266
• McDaniel et al 2004 Family Oriented Primary care. Springer
Verlag