REMODELLING CHRONIC DISEASE MANAGEMENT IN CARDIFF



Programme for Health Service Improvement

Cardiff and the Vale of Glamorgan

REMODELLING

LONG TERM CONDITION MANAGEMENT

Caring for the Better

CONTENTS

EXECUTIVE SUMMARY

1. Purpose

2. Information sources

3. Background

4. Fundamentals of the model

5. Managing the change process

6. Resource implications

7. Conclusion

EXECUTIVE SUMMARY

17.5 million adults report living with a chronic disease in Great Britain (Department of Health 2005), and an estimated 800,000 of those are living in Wales (National Public Health Service for Wales 2005). Chronic diseases are those that cannot be cured and can have a significant impact not only on an individual’s quality of life, but also on that of their family. Such conditions include diabetes, coronary heart disease, chronic obstructive pulmonary disease and neurological disorders such as dementia. It is suggested that 75% of people with such long-term conditions are aged 75 years or over and 45% of people with chronic disease have multiple pathology resulting in the diagnosis of more than one chronic disease.

This places a great demand on the NHS and equates to 80% of GP consultations and over 60% of in-patient bed days. It is estimated that by 2030 the incidence of chronic diseases in the over 65’s will more than double (DOH 2004). Care pathways to manage people with long-term conditions are frequently poorly developed. A whole systems approach is require to design a healthcare system that will be sufficiently robust to not only support the current needs of patients better, but also able to manage the projected growth in demand for services. This requires an approach that not only treats those individuals presenting with long term illness and related complications, but also that invests in health promotion, primary prevention, and risk assessment and management, to ensure people are living healthier lifestyles and can access appropriate services promptly when they require them. Thus, a multi- faceted approach needs to be taken when planning for the future including the need to:

• arrest the increase in chronic disease through public education and effective management of disease pathways

• develop new innovative, integrated community based services to monitor patients’ conditions and address problems promptly and efficiently avoiding hospitalisation where possible.

• develop integrated pathways for that break down the historical barriers within between primary and secondary care, between clinical specialties and between health and social care.

This mirrors the Welsh Assembly Government ‘Designed for Life’ philosophy, which aims to modernise health care by focusing on health and well-being; effective services that are easily accessible and world class standard care.

In addition, it has been well documented by the Welsh Assembly Government that enabling patients to self manage their illness and become ‘expert patients’ is at the core of the future of health care and that services to support patients with long term conditions should be offered as close to the patients home as possible. For Cardiff this will require a shift in emphasis in care provision up the care pathway from secondary to primary and community care.

In reshaping processes in an innovative way the Local Health Boards aim is that individuals will receive excellent care provision but that resources can be redirected to enable new patient centred, primary care approaches to be implemented.

This model links in seamlessly with the Cardiff and Vale of Glamorgan’s Health, Social Care and Well-being Strategy (2005) which addresses the need for innovative action to work across traditional boundaries, share expertise and work within partnerships to address the needs of vulnerable groups as well as the wider public.

PURPOSE

This paper outlines the suggested model of care for individuals with one or more chronic disease diagnoses and intends to provide the overview of a clear pathway for their journey from initial risk assessment and education to the requirement for acute admission to emergency care. In addition, it will clearly describe the change management process and the issues that need to be addressed on order to drive the service redesign forward. It is widely accepted that if patients are effectively managed, the need for them to access emergency care is minimised.

The aim of the model is to provide seamless, equitable, high standard care for all residents in Cardiff and the Vale of Glamorgan with a chronic disease, conforming to a single overall model and approach. It is essential that the Local Health Boards engender a collaborative and co-ordinated approach across the prevention, education, primary and secondary care pathway.

In addition, clear guidelines and pathways based on National Service Frameworks and NICE Guidance will inform Health Care Teams regarding clinically effective care provision, and will act as a framework for individuals so that they can self manage their illness and access appropriate services as promptly as their health requires.

Overall individuals should expect the right care from the right healthcare provider at the right time and as close to where they live as possible.

Information Sources

Welsh Assembly Government (2006) CDM Framework

Welsh Assembly Government (2005) Designed for Life: Creating World Class Health and Social care for Wales in the 21st century

Department of Health (2005) Supporting people with long term conditions

Department of Health (2004) Improving Chronic Disease management

National Public Health Service for Wales 2005: A profile of long-term and chronic conditions in Wales.

Evercare Project Management Team, Implementing the Evercare Programme February 2004

Expert Patient Programme Wales carole.young@valeofglamorganlhb.wales.nhs.uk

Cardiff Health Alliance, Meeting the Challenge The Cardiff Health, Social Care and Well-being Strategy 2005 – 2008

Vale of Glamorgan Health Social Care and Well-being Strategy 2006-08

Cardiff Local Health Board Development of a Community Diabetes Service for Cardiff (2004)

Welsh Assembly Government / Diabetes UK National Service Framework for Diabetes (Wales) update (2002)

Background

There are multiple concerns with respect to the current organisation and delivery of services to people with long term conditions such as Diabetes, Coronary Heart Disease, Chronic Obstructive Airways Disease and Stroke. Whilst at one time such chronic diseases were met with a secondary care clinical response, it is increasingly accepted that, with an ageing population, chronic disease is an every-day part of many people’s lives. With appropriate community based support most of these people can pursue a long and fulfilling life with minimal resort to healthcare services. The system of care has been slower to respond to this paradigm shift and as such there are many opportunities to re-model services to better meet the expectations of the public for now and into the future.

In remodelling the local service it is recognised that much work has already been achieved for example in the provision of training, the development of skill mix, particularly in nurse led management of people with long term conditions, and in the promotion of self-care. However much of the specialist resource for care remains in secondary care areas including in some cases undertaking simple annual reviews. The introduction of the new General Medical Services Contract places renewed emphasis on the important role of primary care in providing first line management of people with chronic disease. There are concerns that the current division between primary and secondary care de-skills practitioners in primary care and community services and is not an effective use of resources. Secondary care services therefore need to be re-designed to provide a community focused services that provide direct support to GP practice in the routine management of patients, and in providing rapid access to specialist clinical advice and support, assessment and pathways to consultant care for patients at risk or in times of crisis. Access to a hospital bed is the end point of this model, but should also be seen as a system failure in managing a patient’s condition.

Now is the ideal time to grasp new opportunities provided through the investment made in the implementation of the new GMS contract and the additional resources made available to achieve the Access 2009 targets within Designed for Life.

It is therefore, important to map the current situation, build on and develop existing good practice as part of an overall service redesign to provide a patient and community focused pathway. Service redesign should start with the public and engage key stakeholders to create an innovative, collaborative approach to problem solving. In mapping current and new care pathways there is a need to overlay this with proposed activity levels to enable the appropriate allocation of resources to follow the patient.

The way forward is clear and that is to empower individuals to self manage their condition and care for them in the community for as long as is possible by giving them clear pathways and prompt access to specialist services when they need them. This will release capacity in the secondary care areas for patients with more complex disease patterns and needs for healthcare.

Future service design models can be informed by the Population Management pyramid which shows that the majority of patients require a lower order of support, but that the majority of resources are invested in the smaller numbers of high risk patients.

RATIO OF SHARED PROFESSIONAL CARE ACROSS THE LONG TERM CONDITIONS POPULATION BASE

Fundamentals of the Model

The model consists of a 4 tier pyramid that reflects disease processes, the impact on a population basis and the required balance of health service response. The model suggests that 70-80% of individuals living with a chronic disease manage their condition on a daily basis with a requirement for a level of support that can be provided within primary care. The remaining 20 – 30% have more complex conditions requiring a shared care model integrating primary care and community based specialist multidisciplinary care. Only 3% of individuals have highly complex, multiple chronic conditions requiring intensive support from a range of services, often within the secondary care setting. In order to achieve a cohesive and effective process it is important to look at all aspects of the Pyramid as an integrated whole as each part affects the other.

Health Promotion / Risk Assessment

Health promotion is an essential part of the pyramid. However this paper is not concerned with the population based approaches to promoting health – these are addressed through the LHBs’ wider Promoting Health and Well-being Strategies, for example in promoting positive lifestyle choices for the general and at risk population.

Empowering individuals to care for themselves is a key function of health staff via education and screening and intervention protocols that prevent and/or detect illness early including referral to appropriate services such as exercise referral, smoking cessation and community food projects. An agreed collaborative approach to such health promotion linking population wide approaches to healthy lifestyles to targeted interventions by health professionals with patients at risk is essential.

The following sections aim to explore the future model in relation to the population pyramid and the remodelling required to improve services.

Level 1 – Self Care support / management

This section is concerned with services to be provided for people newly diagnosed with a chronic disease and their early and on-going management to maintain wellness. This will be standardised at each risk level through a ‘Year of Care’ pathway that outlines the expectations of patients and staff in relation to the package of care that is offered.

Patients are recognised as having a chronic disease normally through a routine GP appointment. Following diagnosis a risk assessment will be performed by a competent, appropriately trained primary healthcare professional to classify their risk. From this an assessment can be made to whether they can be managed within primary care, or whether referral to specialist nurses/therapists is required. In cases of high risk, a consultant referral may be indicated.

Each patient who is newly diagnosed with a chronic disease will be advised to attend a group-based lifestyle education programme as part of their treatment using an education by prescription approach. This would include a combination of universal and disease specific elements. This approach is of proven effectiveness and the aim would be for patients to self manage their disease and learn to understand the care pathway to enable them to access appropriate professionals at appropriate times.

Specialist multi-disciplinary community based long term condition teams will provide initial education and/or provide support to practice based staff to fulfil this role. Continuing professional development for practice staff to enable them to manage their caseload of lower risk patients will also be part of the role of the LTC teams. These teams will be staffed through re-modelling the current resources based in secondary care and in community nursing and therapy services. LTC teams will be based in, and operate from, Primary Care Resource Centres.

Patients with an uncomplicated stable condition will receive care appropriate to the new GMS contract from their practice, often undertaken by the Practice Nurse or in some cases by the District Nurse if domiciliary visits are required. In some cases practices may wish to develop extended services as Practitioners with Special Interests (PWSis) providing an intermediate level of services between primary and secondary care on a wider population basis.

As a minimum, and to fulfil GMS requirements patients with a diagnosed chronic illness will be offered an annual review, often undertaken by the practice nurse, including a standard risk assessment of their health and well being. Dependent on the outcomes of the assessment the patient may require clinical review within the practice by the GP or will be referred to the LTC Team. In addition, the annual review will be the opportunity to re-assess the individual’s knowledge and address any issues through further education as necessary.

The Practice will also identify patients who require annual screening, but who require a home visit. These patients will be visited by the District Nursing Service or Practice Nurse as appropriate.

Level 2 – Disease / Care management

This section is concerned with care that should be provided where an acute problem arises with a patient or for those individuals with more complex needs.

The Practice Nurse should be able to provide telephone advice to patients, using clear protocols, if the patient notices changes in their condition or has any questions regarding their illness. This may lead to a GP appointment or direct access to the LTC team.

If a patient has an acute exacerbation of their illness they should also contact their GP who will be able to assess if access to the LTC team is required. The LTC team will include a range of general and disease specific specialist practitioners from in nursing and therapies with access to consultant medical support. These teams will be based in primary care resource centres, providing elective and rapid access appointments and telephone advice to primary care clinicians. Rapid access to such teams is generally not currently available and consequently management options to patients in crisis other than hospital admission are limited. The aim would be to provide a pathway for care that is able to promptly assess the patients’ condition within their locality and mobilise community services to support the patient return to a stable condition.

A ‘self care’ treatment plan for the patient to follow, with support from the practice would be provided or a consultant referral if appropriate. The consultant would provide the gateway to emergency admission if this was required. Clearly in some cases direct communication between GP and Consultant would still be required to expedite admission, and this would occur through ‘Bed Bureau’. This would be subject to clear protocols based on an assess to admit policy. Hospital admission should generally be seen as a system failure.

The overall aim is to care for the patient in the community where possible. If patients have complex or temporary needs and require some professional support, referral to generic support services such as the Acute Response Team, Reablement teams, District Nursing Services, Elderly Care Assessment Service or voluntary organisations to avoid hospital admission would be considered. These options are most appropriate for people with multiple pathology and/or older frail patients who require more complex care. These services would be accessed from a single point.

It would also be necessary to consider how patients could access advice out of hours and this could be achieved through the existing GMS out of hours services, with patients clearly advised that this will be the appropriate route in their care management plan.

Ideally patients should only be admitted into acute emergency beds following advanced assessment by specialists and where there is no other option available. If patients are admitted they should return to the care of the primary health care team on discharge with a recommendation for active review by the Practice Nurse or GP. Again there maybe a need to involve the acute Response team, Reablement services or the voluntary sector if the patient requires additional, short term support.

Level 3 – High Complexity patients

Patients with highly complex needs, who make the greatest demand on services can be identified in relation to factors such as multi-pathology; frequent use of GP resources, frequent admission to hospital or a complex prescribed drug regime.

These patients, and their carers, will be case managed Specialist Practitioners, who will co-ordinate services across health care specialties, across the primary, intermediate and secondary care pathway and across health, social and voluntary sector service provision. If patients do need to be admitted from these case loads the Case Manager can follow the patient at an early stage to expedite discharge and provide support and review in the community post discharge.

These Practitioners will form part of local LTC teams and maintain a close relationship with GP practices in maintaining patients at home. In some practices the practice nurse may be resourced to fulfil this role. These practitioners will be resourced through the re-deployment of resources currently utilised to manage people with long-term conditions within the hospital setting.

Both the Department of Health and the Evercare programme concur that patients who develop multiple long term conditions are at high risk of unplanned hospital admissions or long term institutionalisation. The Kensington and Chelsea Primary Care Trust introduced the London Older Peoples Service Development Programme based on the Evercare model of Community Matrons case managing high risk patients and found a reduction of between 7.5% and 16.6% in occupied bed days equating to £1.15million per year with a set up cost of the programme as £173,000 (based on 2004/2005 costs). This ethos will be used as a basis to develop current community, specialist and intermediate care services.

5. MANAGING THE CHANGE PROCESS

This chapter aims to provide an overview of the change process and highlight the specific aspects which require addressing in order to modernise service provision.

In order for the Local Health Boards and their partners to achieve the Service and Financial Framework targets and effectively manage the redesign process, there has to be a fundamental understanding and agreement that the future basis of health care provision will be within the community setting.

This requires a clear message to the public regarding the current excellence in practice within the community setting, the reasons for the redesign, what they can expect from future service provision and what developments are taking place in primary care to support professional teams in the change process. In addition, the public should be engaged in dialogue, to explain that through creating headroom in the secondary care setting this will enable them to access specialist services when they require them in the community, which should promote consumer confidence.

Quality and Outcome framework data relating to the new GMS contract has shown promising results in relation to the standard of care already provided in the community. However, if there is to be a shift from caring for individuals in secondary care as proposed, it is imperative that re-allignment of the current staff and non- staff resource mirrors this. Funding allocated by the Welsh Assembly Government to achieve the 2009 Access targets may be used to facilitate these shifts. There is little scope for new investments from other sources as the health community will be facing a challenging financial position for some time to come. Resources will be allocated to reflect the enhanced specialist support that will be required to assist primary healthcare teams caring for individuals especially in areas of high deprivation and who care for large numbers of vulnerable groups. Reductions in the use of admission, to community based models of care will need to be coupled with shifts in resources to support the model.

To achieve the vision of a truly integrated service it is essential that professionals from primary and secondary care engage to drive forward excellence in practice and break down the historical barriers to create a single, seamless care pathway which provides the right care in the right place at the right time.

5.1 The structure of the change process

Senior partners from the 5 key stake holding organisations, in line with the Framework for Health Service Improvement, have to sign up to the redesign proposal and identify champions to drive service modernisation forward. Once the general principles of the model have been agreed it is important to devise terms of reference for steering groups to take the model forward for each specialty within the chronic disease framework. These steering groups should comprise of professionals from the multidisciplinary team incorporating both primary and secondary care; the voluntary sector and patient representation where appropriate. From these core groups sub groups can be created to work on specific aspects of care management and feed into the core group and other advisory groups for ratification prior to implementation.

Although tight targets and deadlines necessitate prompt action in the change management process, it is also important that changes are implemented incrementally and at a pace that is sustainable. The PDSA cycle (plan, do, study, act) would be a good basis for some projects in the change process, as it enables pilot studies to take place in order to gain valuable data on the effectiveness and implications of the change so it can be refined to enable wider scale implementation.

Clear audit criteria should also be decided upon prior to the change process to ensure robust evaluation processes are integral to the change process. This audit process should not just provide quantitative data on reduced waiting times, admissions and referral to secondary care, but should also provide information on patient experience and treatment outcomes.

Actions required

1. Named management and clinical leads for each partner organisation to be nominated and the model principles agreed

2. Steering groups for each disease group to established

• Diabetes

• Chronic obstructive pulmonary disease

• Coronary Heart Disease - Heart Failure / Unstable angina

• Cerebral vascular accident (Stroke)

• Epilepsy

• Musculo-skeletal

Possible future pathways

• Mental health - depression

• Parkinson’s Disease

• Falls

• Gastro-intestinal – Liver disease

3. Target driven ‘Year of Care’ pathways and management plans for each condition to be developed

5.2 Public and professional engagement

In order for any change process to be effective it is imperative to include members of the public and key professionals in the planning process. This will ensure redesign is truly patient focused and mirrors community need, but also addresses the requirements and constraints of the health care environment. Each care pathway redesign will start with patient engagement

Actions required

1. Patient / voluntary sector representation will be sought for membership to the steering groups

2. Patient perceptions experiences will be sought through:

• Observations of care

• Patient stories

• Public meetings

3. Regular updates for the public on service development

• Newsletters

• Engagement with the Community Health Councils

• Website updates

5.3 Patient education and self management

It is widely accepted and clearly documented both by the Department of Health and the Welsh Assembly Government that standardised education of individuals with chronic disease can empower them and is fundamental to self management. This would ensure individuals take ownership of their health and recognise how, where and when to access appropriate services. Importantly such structured education is known to contribute to reduction in demand on health care services.

The N.I.C.E appraisal 60 relating to diabetes states

‘Given the relatively small costs associated with educational programmes, only small improvements in terms of morbidity or health-related quality of life are needed to make educational interventions cost effective’

Historically, resources in relation to patient education have been allocated to post clinical-event and excellent rehabilitation courses have been established for example in cardiac rehabilitation. However, the preventative, self care education for individuals living with chronic disease available to patients in Cardiff and the Vale of Glamorgan is variable, differing in content, structure and quality throughout primary and secondary care. Traditional models of education tend to favour a one-to-one approach to education with patients. The quality of this education will largely be dependent on the enthusiasm and commitment of individual professionals rather than any overarching systematic approach.

In many cases, if planned efficiently, multidisciplinary education could be provided on a group basis to ensure better use of resources and will place greater emphasis on the responsibility being placed on individuals to self manage their condition and reduce dependency. Although there are individual projects who undertake planned group education for certain vulnerable groups on specific conditions this is not widely available.

There is a need to introduce a more systematic approach to offering patient education on diagnosis, linking it to the wider group programmes such as smoking cessation and exercise referral. In order to provide a holistic programme which ensures no duplication of effort core healthy living sessions will be delivered alongside a menu of disease specific modules. These will be delivered by the multi-disciplinary LTC team. Individuals will choose modules as appropriate and this will be provided on a rolling programme throughout the year.

Resources, expertise across clinical disciplines and disease areas and knowledge and skills will need to be pooled to enable implementation of a collaborative standardised course. Course will also be adapted to suit the needs of specific communities; vulnerable groups.

The Practice Nurse or GP would then be responsible for ongoing knowledge assessment and education updates. The ability to access specialist training such as the multidisciplinary team and the expert patient programme as required.

Actions required

1. An education programme for each long term condition will be recommended by each clinical steering group

2. A central referral system for systematic education for patients newly diagnosed with long term conditions will be developed through the LTC team

3. Structured education courses will be part of the individual’s treatment plan and will include core healthy living modules and disease specific modules presented by multidisciplinary experts.

4. Patient information will be limited to agreed documentation and this will be standardised throughout Cardiff and the Vale of Glamorgan

5. The patient management pathway will clearly state what documentation should be provided at each stage of the individual’s condition and by whom.

6. Each patient will have a knowledge assessment within their condition review by their GP practice

5.4 Professional education

There are two interlinked aspects to professional education. Firstly that individual professionals should have the knowledge and competence to provide clinical care, and secondly specific skills are required in order to teach others professionals and the public members, including paying attention to diversity.

Primary care professionals are by definition generalists, and the depth of expertise in specific long term conditions varies depending greatly on the personal interests, the emphasis placed by the GP practice on education and the available resources. Currently, there are well evaluated courses offered for Practice Nurses at different levels however, they are not standardised across the full chronic disease spectrum and no minimum education level is required to undertake clinics.

The table below shows a snapshot of the level of training, as of February 2006, of Practice Nurses in three key chronic disease areas.

|Table 1 |CARDIFF |VALE OF GLAMORGAN |

|DIABETES |

|3 Day course |70 |21 |

|Update in last year |19 |11 |

|Diploma course |25 |2 |

|CHD |

|3 Day Course |23 |10 |

|ASTHMA |

|3 Day Course |40 |5 |

|Update last year |2 |5 |

|Diploma Course |13 |3 |

(NB: Total nurses in Cardiff: 128 / Total Nurses in the Vale of Glamorgan: 42)

It is proposed that the champions are identified, from the multi-disciplinary team, with specific clinical interests to become advanced leaders who can deliver accredited diploma level courses within localities as a distance learning package for a wide range of health care professionals. This would support the further development of a high level of expertise in primary care and incrementally increase the confidence of healthcare professionals in dealing with complex problems and when liaising with specialist teams. Ultimately, it would ensure evidence based care and information is maintained on a Cardiff wide basis.

It could also be possible that a group of practices in each locality could work together, in a network arrangement, each providing different clinical specialist input which would decrease the amount of professionals requiring education. This would ensure safe management of the most complex patients in the community setting

Actions required

1. There will be minimum standards of knowledge and expertise expected of any Practice Nurse who is undertaking nurse led LTC clinics linked within the year of care pathways – this will become part of the core job description.

2. Standardised education courses will be provided for specific chronic diseases

3. All Practice Nurses should provide evidence of continued professional development within the field of long term conditions.

4. Clinical champions will be identified to lead multi-professional education

5. Specialist nurses will be expected to hold an advanced nurse practitioner degree level certificate.

6. Staff providing education to colleagues and patients will be required to demonstrate competence in teaching and training

5. Effective use of specialist services – Long Term Condition Teams

In order that specialist services are used to the optimum it is necessary that a purely patient centred approach is used to focus care as close to the patient as possible. Clearly defined criteria for transfer of patients between key aspects of the integrated patient pathway will need to be developed and adhered to.

GPs will be responsible for the patients care within the existing GMS framework and new enhanced services or GP with special interests (GPWSI) services may be developed as appropriate.

Current hospital based specialist nursing and therapy teams will form the core of new Long Term Conditions Teams and will in the future be managed in the community, whilst retaining clinical links with secondary care specialties. The role of specialist nurses and therapists will be redefined to incorporate an advisory and support role to primary care, with a defined caseload of patients with more complex or immediate needs. The current routine caseload of these staff will be eliminated to support this role.

Effective referral mechanisms and target driven treatment within secondary care will ensure effective use of resources reduce admissions to hospital. Rapid access ‘hot clinics’ will be developed and the ability to provide consultant led community based and/or virtual clinics. A core element of the success of a shared care model will be robust integrated IT systems where notes can be shared electronically between all professional groups.

Actions required

1. Current services need to be mapped to enable the transfer of resources into local long term condition teams

2. Case managers will be assigned to each complex patient in line with the unified assessment process

3. Specialist LTC teams will be managed within the community setting and will work as an integral part of the intermediate care services and local resource centre structure.

4. Multidisciplinary roles will be redefined and will cross boundaries between primary and secondary care

5. Collaborative documentation will be used for all individuals with long term conditions and the IT infrastructure will be developed to manage this safely via Informing Healthcare

5.6 Acute care / high care patients

As suggested previously, patients who are frequently accessing GP services or are admitted to hospital on a regular basis should be highlighted and provided with a case manager to co-ordinate services and avoid hospitalisation.

There is considerable debate over who is best placed to oversee these individuals. It is clear however that there will be no new resources and case managers need to be identified from within the existing workforce and resource designated to supporting people with Long Term Conditions. Case managers therefore may come from the body of practice nurses, district nurses, and specialist nurses. The role will need to be resourced through ensuring that all organisations within the healthcare system are focussing appropriate resource at those at high risk, and re-deploying resources currently locked in hospital based models of care.

The most important aspect is that the patient has a point of contact that can provide advice or refer onto an appropriate healthcare professional should this be necessary rather than the patient requesting emergency care.

Actions required

1. The role of case manager requires local definition

2. A definition of patients eligible for case management will be identified, to inform the capacity requirements of this role

3. Intermediate care / enhanced community care services will be integrated and will accept referrals from all sources

4. Communication will be improved to enable ambulance crews to sign post regular callers who are at risk patients for further assessment

5. The telemedicine trial will be evaluated and if successful will be rolled out throughout Cardiff and the Vale of Glamorgan

6. ‘Hot clinics’ will be created within specialist services for prompt access of acutely ill individuals

7. Combined GP / Consultant clinics will be provided in the community

6 Resource Implications

In the current economic environment within the NHS, there are limited new resources to drive the change process forward; however there is considerable investment in services for people with Long Term Conditions, albeit there is not confidence that these services are equitable or provided on the basis of need.

It is clear that the first step is to map existing services and highlight constraints and bottlenecks and then re-engineer resources to improve patient flow and services. In line with policy documents this would mean the shift of resources from secondary care into community based services. It is only when systems are working efficiently that true service improvement costs can be estimated.

Proactive long term modernisation may require pump priming investment to drive the change process forward with clear audit tools to measure success. In order, that the change process is effective the need for effective change management processes and investment in public and professional consultation can not be underestimated.

Small pilot studies be used to provide data on the efficiency and impact to services and these should be linked to the achievement of government targets. Some changes may have a direct impact in reducing resource requirements and others in softer benefits such as reduction in bed days and hospital admissions.

It is certain that doing nothing and not investing time and resource at this stage will create major resource and health implications for future generations.

7 CONCLUSION

Patients with Long Term Conditions are the highest users of healthcare services and this is set to rise substantially over the next 25 years. New systems will be required to address healthy living and early detection of diseases thus reducing complications and the burden to the NHS as a whole.

Evidence suggests that there are inequalities in access to services for patients and high risk groups, usually the elderly with multiple pathologies and they are accessing emergency care more frequently than is necessary.

There is a need to streamline and standardise the management and treatment of patients with Chronic Diseases with protocols and pathways and this can only be achieved by a whole systems approach to disease management from health promotion to acute illness.

In addition, there has to be a shift in emphasis from secondary care towards primary care, providing fast efficient care within the community which will free up secondary care for the more complicated specialist cases.

In order to achieve this an incremental approach needs to be taken using the Plan, Do, See, Act cycle and it is imperative to involve both the public and professionals in service redesign in order for changes to be implemented successfully.

This is a long term model that will take some years to achieve but it is felt that the excellent practice that is already taking place can be built on and lessons learnt for future planning, which will enable some changes to show marked efficiency improvement very quickly.

The main ethos of this model remains that individuals should expect the right care from the right healthcare provider at the right time and as close to where they live as possible

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LEVEL 3

HIGH RISK PATIENTS

CASE MANAGEMENT

LEVEL 2

HIGH RISK PATIENTS

CARE MANAGEMENT

LEVEL 1

70-80% OF A CHRONIC CARE MANAGEMENT POPULATION

HEALTH PROMOTION

3 priorities for service redesign stated by patients and professionals

1. Standardised education for both patients and professionals

2. Improved information provision and better communication within and between the healthcare teams

3. Prompt access to specialist advice / services

Chronic Disease Patient Education Programme

Step 3 – Practice Nurse / District Nurse

Step 4

Step 1

‘Looking after yourself’

• Healthy eating

• Exercise

• Stopping smoking

• Drinking less alcohol

• Stress Management

• Returning to work

Step 3 –

Knowledge review / update

• Annual Review

• Knowledge Assessment

• Referral for one to one (eg dietetics)

• Re-referral for group education

Step 2

Disease specific modules

• Diabetes

• Angina

• Respiratory

• CVA

• Heart Failure

• Epilepsy

• Musculoskeletal

• Gastro-intestinal

• Neuro -muscular

Expert Patient Programme

‘Coventry PCT has put in place a GPSI service that triages out 80% of all primary care referrals to the hospital as part of a clinical assessment service. This was done with the agreement of the Hospital consultant who is now developing specialist clinic for diabetes complications within secondary care, with the view that all general diabetes care should take place in the community’

Juliet Hancox – Coventry PCT

EXERCISE PROGRAMMES

SMOKING CESSATION

VOLUNTARY SECTOR

SPECIALIST SERVICES

• CARDIAC REHAB

• PULMONARY REHAB

• CRRU

• HEARTLINK

• HEARTELY

MDT

• Physio

• Dietician

• OT

• Podiatry

• Psychology

• Social worker

• Pharmacist

•

SPECIALIST NURSE

• Diabetes

• Heart Failure

• CHD

• COPD

• Epilepsy

• CVA

INTERMIDIATE CARE TEAMS

• ART

• CRRT

• ECAS

• DAY CARE

CORE TEAM

• GP

• PN

• DN

HOUSING

EXPERT GENERALIST

RETURN TO WORK[pic]

BENEFITS

SPECIALIST CONSULTANT

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