Transcript Community Matrons

Community Matrons
June 2007
Community matrons: the aim

Improve health outcomes for people with long term
conditions

Offer a personalised care plan for vulnerable people
most at risk

Reduce emergency bed days by 5% by 2008
(2003/4 baseline)

Improving care in primary and community settings
The current situation
People with long term conditions:
Account for 80%
GP consultations
50% of medicines
prescribed for people
with LTCs are not taken
People with LTCs take up
10% of inpatients beds,
but account for 55% of inpatient days
A high proportion of
these VHIUs are not
on a DN caseload
Framework for managing long term
conditions
10%
Case
Management
20%
Disease Management
70%
Supporting self-care
Referral Criteria

Three or more active long term conditions

Three or more A&E attendances/ unplanned
admissions

Top 3% of GP users

PARR score of >50%
Case Management- what we do
planning
co-ordinating
Supporting
people with
long term
conditions
reviewing
managing
Benefits of Case Management

Client-centred

Improves clients’ functional abilities

Effective use of resources

Brings together primary and social care

Prevents unnecessary admissions

Reduces length of stay in hospital
The Community Matron’s role

Comprehensive assessment

Innovative case management

Advanced clinical skills and medicine management

Marshalling of resources and co-ordinating primary and social
care

Patients empowerment opportunities
Key Challenges

Developing a workforce

Competencies, education and training

Supervision and mentorship

Data and information for case finding and risk
management

Systems change and integration with other services
NHS modernisation and the Case
Management approach (1)
Quality and
Outcomes
Framework
GP contract
Practice-Based
Commissioning
NHS modernisation and the Case
Management approach (2)

Intermediate care

Connecting for health

Single Assessment Process

Extended and supplementary prescribing

AHP role development

New pharmacy contract
Community Matrons
“Through the unique combination of
comprehensive assessment, proactive clinical
intervention, marshalling of resources,
assessment of the quality of care and coordination of acute primary and social care,
enable people with multiple conditions,
affecting all areas of daily living to remain in
control of their own lives”
CNO Bulletin, August 2004
PARR: Background

The King’s fund was commissioned to develop a software tool
for use by Primary Care Trusts to systematically identify
patients who are at high risk in the future of readmission to
hospital via emergency admissions.

The PARR case finding algorithm tool became nationally
available from September 2005.

The software package was made freely available to NHS
organisations on 1st February 2006. The current software
package, PARR+ combines PARR 1 and PARR 2
PARR: How does it work? (1)
• Clearly a large share of hospital admissions cannot be
prevented or avoided. The PARR case finding algorithm does
not identify patients randomly.

PARR uses prior hospital discharge data to identify patients at
high risk for re-hospitalisation in the 12 months following a
“reference” hospitalisation.

PARR aims to identify patients in real time who have a high
probability of subsequent emergency admissions while they are
hospitalised for certain “reference” conditions for which
improved management may reduce the risk of rehospitalisation.
PARR: How does it work? (2)

PARR focuses on a range of “reference” conditions (including
congestive heart failure, COPD, diabetes) where timely and
effective case management can help reduce the risks of
hospitalisation.

An emergency hospital admission for a “reference” condition is
a “triggering” event. This admission creates a “risk score” for
the probability of another admission in the next 12 months.

PARR 1 and PARR 2 both use Hospital Episode Statistics
(HES) data to produce a ‘risk score’ showing a patients
likelihood of admission within the next 12 months.

Risk scores range from 0 – 100, with 100 being the highest risk.
Identifying Patients with PARR

We identify high risk patients, referred to as Very High Intensity Users
(VHIU), and offer them care using a case management approach to
provide proactive, co-ordinated and joined-up care in community
settings.

Evidence shows that intensive, on-going and personalised case
management can improve the quality of life and outcomes for these
patients, reducing emergency admissions and enabling patients who
are admitted to return home more quickly (DOH 2007).

Community matrons must be targeting resources to the VHIU in order
to help reach the PSA target of improving care for patients with long
term conditions, and reducing the use of emergency bed days by 5%
by 2008 (DOH 2007).
HIDAS

Developed web base information system that
acts as a reporting tool for the PCT’s data
warehouse

Features include: inpatient and outpatient
activity, predictive tool, and long term
conditions
Outcomes

Being a new service it is important that we monitor
our outcomes to demonstrate our success and
inform the development of the service

We have carried out a six month audit from 1st
October 2006 to 31st March 2007

The information represents two caseloads with a
total of 57 patients
Age and sex of Patients
30
25
20
15
Count
We accept patients aged 18 and
over, but the highest number of
patients falls between the 75 and
85 age group.
10
5
0
18-65
65-75
75-85
85+
Male
There are slightly more
female patients, with a ratio
of 27 male: 34 female
Female
Source of Referral
18
16
14
12
10
Count
8
6
4
2
0
Pa
GP GP
AC
IC
T
rr/
Di
Re S
Hi
co
da rec
t
rds
s
V
C
Co
2
O
ns ° Ca ol un omm the
r
ult
tar
an re
y S . hos
t
ec p.
tor
Most patients
are
proactively
identified by
community
matrons, with
30% (18) of
patients
identified
using PARR/
Hidas.
Primary Diagnosis at Referral
25
20
15
Series1
10
5
0
C
M
CK
Re
N
en O th Dia
D
s p ard eur
b
e
t
iac
et
al
olo
r
ira
es
to
gic He
ry
al
al
th
Ca
CV
M
rd S K
A/
iac
TI
A
We often manage
patients with
several coexisting
conditions, but
referral is usually
triggered by a
primary diagnosis
Primary Need for Case Management
25
20
15
Series1
10
5
0
D
gt
M
gt
M
d
or
o-
se
ea
is
C
C
LT
n:
io
at
uc
Ed
e
ar
es
in
ic
ed
M
C
The
community
matron role
can be
divided into
four key
interventions.
This graph
shows the
distribution of
our key
intervention.
Prevention of Admission

There is currently much debate about how to
define or verify a prevention of admission,
i.e. how does one prove that something has
been prevented?

We have compared admissions and GP
usage before and during case management.
Hospital admissions compared

Comparing the figures before and after case
management, a significant reduction in admissions
can be seen

From the 57 patients, there were 142 admissions
recorded in total in the previous 12 months

Since being case managed, patients have had 31
admissions in 6 months

Of those admissions, 28 were seen to be
unavoidable or timely and 3 were preventable
Number of Hospital Admissions
30
25
20
Series1
15
10
5
0
Unavoidable
Preventable
There is a significant
reduction in
admissions for
patients during case
management
compared with prior
to case management
Over 90% of
admissions of
patients who are
being case managed
are unavoidable
Reduction in GP home visits
200
180
160
140
120
100
80
60
40
20
0
Prior to case management
During case management
Extrapolating
figures from the
audit to create
a full year
effect, case
management
has reduced
the number of
GP home visits
by 162 visits a
year
Measuring potential admission
avoidance

Whilst we have gone to lengths to compare
admissions before and during case
management, we are also documenting
occasions where we feel that an admission
has been prevented

We have divided these into acute episodes
and extended episodes of care that
potentially lead to admission avoidance
Reduction to Service Usage following
Acceptance onto Caseload
80
70
60
50
Series1
40
30
Community matrons
have orchestrated 39
acute episodes where
admission to hospital
may have been avoided.
20
10
0
Ac
ute
E
pis
od
e
Ex
ten
de
E
Ea
rl y
pis
od
e
GP
Di s
ch
arg
e
or
Oo
H
Co
nta
ct
Extended episodes of
care have potentially
prevented 76 admissions
The future

Community matrons around the country have sent
feedback to the Department of Health asking for help
in qualifying a prevention of admission

A preliminary patient and carer satisfaction survey
will be sent to all patients on the caseload this
summer

A more detailed 12 month audit will be carried out in
November which will include cost saving information
Case Study (1): Introduction

90 year old gentleman

Medical History of COPD, AF, and Hypertension

Discovered via PARR: PARR score of 86%

Command of the English language poor

Extremely hard of hearing

Lives with his wife, his son, daughter-in-law, and their three young children in a
three bedroom council house

Daily care worker visit for washing and dressing

Admissions to hospital in the year prior to Case Management: 6 admissions
equalling 39 bed days from April 2005 to April 2006
Case Study (1): Assessment Outcome

Poor understanding of and compliance with
medication

Inability to use inhalers and nebulisers properly

Lack of follow up after hospital interventions

Urinary incontinence

Frequent exacerbations of COPD followed by
hospitalisation
Case Study (1): Intervention

Referral to Audiology

Use of an interpreter for teaching purposes

Medicines management / Change of medication

Education re use of inhalers, using volumatic, and nebulisers

Organising a course of antibiotics and steroids on repeat
prescription

Education re signs and symptoms of exacerbation

Family support
Case Study (1): Outcome

No admissions to hospital in the first 9 months of case
management

Improved communication

Proper use of medication, inhalers and nebulisers

Supply of pads for urinary incontinence

Patient and family feel supported

2 hospital admissions and 10 bed days following case
management
Case Study (2) : Introduction

80 year old man, lives alone

Referred by Rapid Assessment Unit

Fulfilled the criteria because





Impairment in instrumental ADL
3 or more active LTC
Top 3% of GP users
High risk triggers: falls and living alone
COPD, IHD, Renal impairment, Chronic anaemia, Chronic
gravitational oedema, L eye blindness, significant speech
impairment, faecal incontinence.
Case Study (2): Prior to case
management

In previous 12 months had






1 admisssion
1 A&E attendance
2 ICT care episodes
13 GP home visits
6 GP surgery attendances
Main focus of case management was improving
social situation, care co-ordination, medicine
management, monitoring health and acting as the
patients advocate.
Case Study (2): Assessment Outcome

The patient was sleeping in a low cane chair and legs were
extremely oedematous, affecting mobility, causing falls and skin
breakdown

Breathless and fatigued due to anaemia

Faecal incontinence secondary to high faecal impaction

Poor compliance / understanding of medications

Poor social care due to reduced ability to express his needs
and substandard carer input

Social isolation.
Case Study (2): Intervention












Obtained new suitable chair from HES
Referred to ICT OT for aids for bed
Referred to DNs for skin care and compression hosiery
Changed diuretics
Requested carers ensure assistance to bed was provided in evenings
Monitoring of Hb and referral back to RAU for blood transfusion
Introduced medication policy for carers to assist with meds and inhalers
Monitoring of bowels and laxative regime
Wheelchair referral
Referral to day centre, befrienders and good neighbours
Ongoing monitoring of health; bloods, BP, Pulse, temp, chest auscultation, weight,
leg measurements.
Ongoing social input; order meals for weekends, liaise with good neighbours,
feedback to care agency, act as advocate in complaints to care agency, follow up
repairs and modifications to council
Case Study (2): Outcomes

No admissions or A&E attendances in 7 months of case management

3 GP home visits, CM acts as first port of call

Improved mobility, legs less oedematous

Less patient frustration

No further faecal incontinence or constipation

Better compliance with medications

Improving social situation and care input

Example of where case management may have averted a future admission or
crisis: development of postural hypotension (increased risk of falls / injury) when
dose of thiazide increased, so dose changed.
Case Study (3): Introduction

72 year old man

Lives with wife, who is main carer

Referred by elderly care consultant

Fulfilled the criteria because:

3 or more LTC and 3 or more A&E attendances

Impairment in instrumental ADL

High risk triggers include: exacerbation of LTC

PMH: epilepsy, COPD, aortic stenosis, indwelling urethral catheter
Case Study (3): Introduction contd…

5 admissions

2 A&E attendances

5 + GP surgery attendances

Under care of 5 consultants

Presenting problems:





Catheter bypassing
repeated UTIs
bilateral lower leg pain and oedema,
fluid overload
medicine management.
Case Study (3): Assessment Outcome

Patient and carer had poor understanding about his
various medical conditions

Community nurses visiting to re-site catheter (approx
every 2-3 weeks), and catheter bypassing most of
the time

Lower leg pain and oedema, not responding to
analgesia

Attending many different OPA
Case Study (3): Intervention







Liaised with urology consultant and requested review of situation and
consideration of a supra-pubic catheter. Also requested review of
medication
Wrote to consultants explaining rationalising of care and now under the
care of Elderly Care Consultant and CM
Medication review
Educated patient and carer about pts medical conditions and put
individual care plans in place. Pt weighs himself daily and reports to CM if
increase/decrease in weight. Pt and carer will observe urine output and
contact CM if infection suspected. Pt reports any signs/symptoms of
epilepsy promptly
CM is first point of contact and then will liaise with appropriate member of
the MDT.
CM organised a Doppler and prescribed compression hosiery.
CM liaised with elderly care consultant and arranged for the RAU to
administer IV diuretic when weight, leg oedema and abdo distension
became a problem
Case Study (3): Outcomes

1 emergency admission (appropriate, but avoidable)

No GP surgery attendances or home visits.

1 ECP visit (no action taken)

1 episode with ICT

Experiences nil bypassing with supra-pubic catheter and DN changes
every 12 weeks.

Under the care of 3 consultants.

Regular and planned visits by CM to monitor vital signs, monitor weight,
measure abdo, assess pain, monitor epilepsy and offer carer support.
Conclusion
“The case management approach to
LTCs has the potential to have a great
impact on the patient experience and
the effective and efficient use of
resources”