Transcript Managing Multiple Comorbidities

MANAGING MULTIPLE
COMORBIDITIES
Kevin Hurrell
Crawley GP
Clinical Lead for Diabetes CCCG
Associate Dean HEKSS
Illustrative Case study
Mr GB 67yr old first generation immigrant from Pakistan. Has been a
leader of his local community.
Schizophrenic psychosis diagnosed 1985. On intermittent depot antipsychotic medication for 20+ years
Irritable Bowel syndrome diagnosed 1990
Duodenal ulcer 1993
Hypertension 2002
Type 2 Diabetes 2006
CKD 3a without proteinuria 2010 Adverse reaction to ACEI
Diagnosed TIA 2012 (doubtful)
Drug induced Parkinsonism 2014
Admitted 06/11/2015 following falls. Found to have gone into AF with
tachycardia and hypotension.
Discharged home on fludrocortisone (to be titrated by GP) , madopar (to be
titrated by GP) restarted bisoprolol which patient had stopped (reverted to
sinus rhythm) Admitted under section of Mental Health Act within 3 days of
discharge
Further information on Mr GB
• Psychosis causes paranoia, especially mistrust of family and hospital
• Concordance always an issue and he blames depot medication for his current
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problems
Will not take diabetic medication or consider anticoagulation
Stopped b-blocker as felt it worsened his Parkinsonism
Has annual Mental Health review and care plan update
Has annual diabetes review and care plan update
Is chased up for QOF reviews etc. CKD,BP, TIA, Medication reviews
Usually sees GP 20+ times a year
Has a room in the family home: tolerated by rest of family.
• I have known him for 30+ years and we have a lot of mutual respect
• These multiple comorbidities are a huge
burden for patient, family and NHS
Some comorbid ruminations:
• Diabetes often features
on Venn diagram of
overlapping
comorbidities:
• Mental Health
• Macrovascular disease
• Hypertension
• Microvascular Disease
• Renal disease
• Eye disease
• Neuropathy
• Foot disease
UK National Psychiatric Morbidity Study
2007
• Increased risk of mixed
• Impaired quality of life
anxiety and depression in
patients with diabetes.
Hazard ratio=1.7
• Increased risk of
developing diabetes in
patients with mental health
problems:
• Lifestyle choices,
medication, alcohol
• More sick leave/work
absence/unemployment
• Non-adherence to
management plans and
poor concordance with
medication
• Difficulties with self-care of
diabetes
Stroke risk in Type 2 Diabetes
• General practice
• Associations:
database 2006
• Risk of stroke
increased
• Hazard ration 2.19
• HR as high as 8 for
younger female
patients
• NB Risk for young
women is of course
relatively low
• Risk increased further
with
• Duration of diabetes
• Smoking
• Hypertension
• Obesity
• Atrial fibrillation
Hypertension in diabetes
• Up to 75% of patients
• Ethnicity and familial
with diabetes have
hypertension
• Hypertension and
diabetes share a
number of risk factors
• Ethnicity and familial
history show genetic
predisposition to
dyslipidaemia and
insulin resistance
factors also impact on
cultural behaviours
including lifestyle
choices
• Increased
macrovascular and
microvascular risk
(alongside risk from
hyperglycaemia)
Concept of concordant and discordant
comorbidities
• Concordant
• Share common
• Discordant
• On average we develop
aetiological factors
• Improvements in one
risk area likely to reduce
risks elsewhere
• Treatment choices
increasingly reflect
concordant
comorbidities e.g. choice
of oral hypoglycaemic
agents
one new long-term
condition every 5 years
from the age of 55
• Treatment for one LTC
may have no impact on
other comorbidites
• In some cases treatment
options conflict e.g. use
of l-dopa for
Parkinsonism with
history of psychosis
Hierarchy of comorbidities
• Some comorbidities
easily eclipse others
• End-stage heart failure
or terminal illness will
reduce the emphasis on
tight glycaemic control
• But often the hierarchy is
less clear, especially
when multiple specialties
are involved
How do we prioritise?
• Clinician’s priorities
• Patients’ priorities
• Often disease specific
• Often impact determined
• Often future orientated
• Often ‘here and now’
• Often driven by ‘quality
• Often limited by the ‘burden
indicators’ and targets
(including financial)
• Often results in ‘summative
interventions’: more and
more medications and
appointments
of treatment’
• Often results in ‘reductive
behaviour’: patients become
less and less concordant with
medication and also feel
disempowered
Scale of the challenge
• The 15 million people in England with long term
conditions have the greatest healthcare needs of the
population (50% of all GP appointments and 70% of all
bed days) and their treatment and care absorbs 70% of
acute and primary care budgets in England.
• It is clear that current models of dealing with long term
conditions are unsustainable. Rather than people having
a single condition, multimorbidity is becoming the norm.
• The number of people with 3 or more long term
conditions is set to increase from 1.9m to 2.9m by 2018,
and this will be associated with an extra £5bn p.a. spend.
How might we rise to this challenge?
• Patient-centred
• Shared clinical
consultations
• ‘No decision about me
without me’
• Truly agreed
management plans
which respect and
empower patients
where and when
possible
information across
specialties/GP/commu
nity care…and shared
with patient.
• The Care Plan ideal
• But this is not easy!
House of Care Paradigm
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Single condition services: services dealing with
single conditions only and adopting single condition
guidelines (with attendant dangers of polypharmacy,
and excluding an holistic approach to service users).
Lack of care coordination: people being unaware of
whom to approach when they have a problem, and
nobody having a generalist’s ‘bird’s eye’ view of the
total care and support needs of an individual.
Emotional and psychological support: in particular,
a lack of attention to the mental health and wellbeing
of people with ‘physical’ health problems (as well as
failure to deal with the physical health of people with
mental disorder as their primary long term condition).
Fragmented care: the healthcare system remaining
within its own economy, and not being considered in a
whole system approach with social care or other
services important to people with long term conditions
(e.g. transport, employment, benefits, housing).
Failure to support people with ‘more than medicine’
offers as provided by, for example, third and voluntary
sectors.
Lack of informational continuity: care records
which can’t be accessed between settings, or to which
patients themselves don’t have access.
Reactive services, not predictive services: failure
to identify vulnerable people who might then be given
extra help to avoid hospital admission or
deterioration/complications of their condition(s).
Lack of care planning consultation: services which
treat people as passive recipients of care rather than
encouraging self-care and recognising the person as
the expert on how his/her condition affects their life.
Essentials of the model
• The House model (derived from the Chronic Care Model of Ed
Wagner, and the Diabetes UK Year of Care project is useful for
drawing together the building blocks of integrated care to incorporate
the essential elements of continuity:
• Informational continuity: by which people and their families/carers
have access to information about their conditions and how to access
services; health and social care professionals will have the right
information and records needed to provide the right care at the right
time.
• Management continuity: a coherent approach to the management of
person’s condition(s) and care which spans different services,
achieved through people and providers collaborating in drawing up
collaborative care plans.
• Relational continuity: having a consistent relationship between a
person, family, and carers and one or more providers over time (and
providers having consistent relationships with each other), so that
people are able to turn to known individuals to coordinate their care.
The nitty-gritty problems to resolve
• Holistic, collaborative and integrated care
planning is still elusive
• Too often care plans ‘sit on the shelf’
• Conflicting priorities and hierarchies remain
• All of secondary care remains disease specific
• GPs are best placed to integrate care…but GPs’
working structures are out of date….and there are
huge recruitment and retention problems
What we are trying to achieve in Crawley
• Over 95% of patients with diabetes are seen in general practice (very
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different to community clinic). Service has run for 12 years.
Nurses with special interest at the forefront of the service
Quarterly educational and audit meetings across whole town with
excellent consultant support
Run a ‘low number stop shop if possible’…looking at as many LTCs
as possible
GP records remain the closest to the holistic ideal
Started looking at much more holistic care plans (but visit from House
of Care representatives highlighted the difficulties)
Anticipatory care-planning essential…not just listing present care
package.
Increasing use of ‘Share my Care’: OOH/ SECAmb/ Trust
Trying to influence commissioners to think beyond single year funding
Trying to work with Community Trust to improve Proactive Care
Trying to refine our data on patients at high risk of admission
Trying to use IT within care-planning….