Transcript improving management of long term conditions

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 comorbidities
50
45
40
35
Average
30
no. of
25
prescriptions 20
15
10
5
0
Prescriptions
0
1
2
3
4
No. of chronic diseases
5+
LTC Management
Level 3
Case
Mgt
Highly
complex
patients
Level 2
Disease
Management
High risk
patients
Level 1
Self
Management
70-80% of a
CDM pop
POPULATION-WIDE PREVENTION
CASTLEFIELDS HEALTH
CENTRE (UK)
15% reduction in unplanned admissions
31% reduction in hospital LOS (6.2 to 4.3)
Total hospital bed days fell by 41%
Significant savings
Better patient experience
Improved 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
Traditional Model
Chronic Care Model
SICKNESS CARE MODEL
(Current Approach - Physician Centric)
Counsel re:
Lifestyle
ReviewChanges
Labs
Access
Social/Other
Services
Deal with
Acute Attack
of Disease Reinforce
Positive Health
Behaviours
Talk with
Family
Reassure
Complete
Forms
Diagnose
General
Referral
Consultation
10 minutes
Review/Adjust
Rx and Tx
Routine
Preventive
Care
Source: KPCMI [21]
Review
Care Plan
Review
Modify and/or History
Negotiate Care
Plans
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
• 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 coordination
COMPONENTS OF EFFECTIVE
CDM (2)
Self care/self management - with
information and support
Active management of at-risk
patients
Primary/secondary/social care coordination
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 3/
Coordinating
Care for People
With Chronic
Disease
Step 1/
Informed
Decision
Making
Step 2/
Case Managing
Patients with
Highest Burdens
of Disease in
Community
Step 5/
Measuring
Achievement
Step 4/
Encouraging
Patients to
Become
Confident
and Informed
About
Managing
Their own
Condition
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
admissions
2.2 Combine their acute history with GP practices & Social
Care’s
2.3 Carry out clinical & social assessment in their home &
agree Care Plan with them
2.4 Check & manage their medicines
2.5 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 Condition
Key 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 Programme
4.3 Signpost patient toward other support provided by
voluntary and community sector, local authority, and
others
4.4 Prescribe effective (combinations of) medicines
4.5 Provide tools to support home monitoring and testing
4.6 Engage patient throughout care pathway on improving
self-management
Step 5/ Measuring Achievement
Key Activities:
5.1 Assess baseline
5.2 Monitor progress
5.3 Adjust processes if necessary
5.4 Identify interventions that make a difference,
5.5 Gather effective practice
5.6 Extract learning and share widely
Populating the Process Model
Name/ Step x 5
Question
Question
Question
Question
Learning
Learning
Learning
Learning
1. Review the Steps
2. You are only allowed 4
post-its of either colour
3. Write down your
Learnings/ Questions IN
CAPITALS
4. Name your post-it
5. Put your post-its on the
correct whiteboards
6. 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
4.1
Jane B
LEARNING
Mike A
4.1
Populating the Model
-matching learnings to questions
Name/ Step x
Question
Question
Question
Question
Learning
New
Question
?
Learning
Learning
Learning
Review
1 Common, Special, Missing
2 New work and new ideas: building the new agenda
around LTCs
3 Validity of 5-stage Generic Model
4 Next steps –sharing prototype with you and building new
practice framework around LTCs
5 Thank you!