IMPROVING THE MANAGEMENT OF LONG TERM CONDITIONS

1. 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 improvementtool to support NHS implementation

2. 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

3. 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

4. Prescriptions increase with co-morbidities

5. Level 3 Highly Case complex Mgt patients Level 2 Disease High risk Management patients Level 1 Self 70-80% of a Management CDM pop LTC Management POPULATION-WIDE PREVENTION

6. CASTLEFIELDSHEALTH 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

7. VETERANS’ ADMINISTRATION (USA) • 35% reduction urgent care visit rate • 50% reduction hospital bed days

8. EVERCARE (USA) • 50% reduction unplanned admissions without detriment to health • Significant reductions in medications • 97% family and carer satisfaction • High physician satisfaction

9. 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

10. Traditional Model Chronic Care Model SICKNESS CARE MODEL (Current Approach - Physician Centric) • 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 Counsel re: Lifestyle Changes Deal with Acute Attack of Disease Review Labs Reinforce Positive Health Behaviours Access Social/Other Services Talk with Family Reassure Complete Forms Diagnose Review Care Plan General Referral Consultation 10 minutes Review/Adjust Rx and Tx Review History Routine Preventive Care Modify and/or Negotiate Care Plans Source: KPCMI [21] THE TRANSFORMATION

11. Acute system • Treat the episode • Don’t make the connections And . . . . . . .the patient is more likely to be admitted again

12. COMPONENTS OF EFFECTIVE CDM (1) • Population management & risk stratification - (informing decisions) • Effective registers and integrated records • Evidence–based “care pathways” • Disease management and care co-ordination

13. COMPONENTS OF EFFECTIVE CDM (2) • Self care/self management - with information and support • Active management of at-risk patients • Primary/secondary/social care co-ordination

14. 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

15. 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?

16. 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 improvementtool to support NHS implementation

17. BUT NHS MUST START TO IMPLEMENT! Can we work together to populate an implementation tool by harvesting what we already know?

18. Improving the Management of Long-Term Conditions Step 5/ Measuring Achievement Step 1/ Informed Decision Making Step 3/ Coordinating Care for People With Chronic Disease Step 2/ Case Managing Patients with Highest Burdens of Disease in Community Step 4/ Encouraging Patients to Become Confident and Informed About Managing Their own Condition

19. 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

20. 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.

21. 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.

22. 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

23. 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

24. Populating the Process Model Name/ Step x 5 • Review the Steps • You are only allowed 4 post-its of either colour • Write down your Learnings/ Questions IN CAPITALS • Name your post-it • Put your post-its on the correct whiteboards • Be prepared to explain your post-it question or learning in the review stage • Have a look at other learnings and questions on other steps Question Question Question Question Learning Learning Learning Learning

25. Populating the Model-marking your contributions for the review stage Name/ Step x QUESTION 4.1 Jane B LEARNING 4.1 Mike A

26. Populating the Model-matching learnings to questions Name/ Step x Question Question Question New Question ? Question Learning Learning Learning Learning

27. 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!