09 - Management of Long Term Conditions

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09 - Management of Long Term Conditions ...


     Decision Discussion Information

IMPACT ON STRATEGIC DIRECTION: The aim of the report is to guide the development and

    organisation of services for patients with long term conditions and to inform the Board of the

    national performance targets that must be achieved in relation to this patient group.

FINANCIAL IMPACT: Service redesign in order to produce better outcomes, slow disease

    progression, reduce disability, ensure better management of the sudden deteriorations often

    associated with long term conditions will result in improved quality of life for patients and

    reduced need for admission to hospital.

IMPACT UPON SERVICE USERS: Supporting patients to manage their own conditions will

    empower patients, improve their experience of services and improve their health outcomes.

IMPACT UPON STAFF: The report and decisions made will inform staff of the strategic

    direction to be taken within Hillingdon to manage patients with Long Term Conditions. New roles, e.g. Community Matrons and new responses to service provision will integrate care


    IMPACT UPON INTERNAL AND EXTERNAL PARTNERS: The delivery of the strategy requires work across cultural and organisational boundaries to develop integrated, patient

    centred services which will transform care for patients with long term conditions.

    IMPACT UPON EQUITY: Patients will be provided with a service based on need.

IMPACT UPON PCT OBJECTIVES: The paper demonstrates the strategic direction required

    to support the Local Strategic Partnership priorities to

    1. Improve the health and well-being of the population

    2. Support Hillingdon residents with long term conditions

    3. ensure fair and prompt access to care in Hillingdon

    4. Promote quality of life ,independence and choice

    As well as supporting the four principles identified in Hillingdon's Vision for Health 1. People should receive health care as close to home as possible 2. people should receive the appropriate treatment in the appropriate place at the appropriate


    3. Allow patients to take control of their own long term condition - education and support must be available for them to be "expert patients".


    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING) Date: 25 January 2005 Page No 1


    Contact Name: Esme Young

     Contact Tel No: 01895 452056


    The need for effective management of chronic long term conditions is a growing priority for

    the NHS and has the potential to have a great impact on the effectiveness and efficiency of

    the use of resources across health economies. Hillingdon PCT together with the health and

    social care economy needs to develop a systematic approach to providing care for people

    with long term conditions.


Board is requested to:















1. Context

    1.1 Aim To develop an overall structured and systematic approach to providing care for people with Long Term Conditions, with informed patients interacting in

    partnership with a proactive health care team.

The need for effective management of chronic long term conditions is a growing priority for

    the NHS and has the potential to have a great impact on the effectiveness and efficiency of

    the use of resources across health economies. Both the „NHS Improvement Plan „and the

    planning framework ‟National Standards, Local Action‟ highlight the management of Long

    Term Conditions as a key priority over the next four years.

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 2

The challenge is to work across boundaries both cultural and organisational - and develop

    the integrated, patient centred services which will transform care for patients with long term


    1.2 National statistics

National data indicates

    ? 60% adults in England report a chronic health problem

    ? 17.5 million people may be living with a chronic disease

    ? By 2003 the incidence of chronic disease in people 65 years plus will have doubled

    ? 80% GP consultations relate to chronic disease

    ? 5% of those admitted as inpatients account for 42% of all inpatient days

    ? 10% of those admitted as inpatients account for 55% of all inpatient days

It is estimated that an individual PCT will have somewhere in the region of 825 frequent

    flyers/very high intensity users ( patients frequently using health services and having multiple

    hospital admissions) and an average sized General Practice will have approximately 25

    patients. Of these only 1:4 patients will be known to the District Nursing Service and 1:3 will

    be known to Social services.

    1.3 Drivers for Change

There are a number of drivers for change in the system. They include political will, changes

    in Primary Care contracting the nGMS contract, Pharmacy contract, Practice Led

    Commissioning, National Service Frameworks, Modernisation agenda Agenda for Change,

    Liberating the Talents, Quality and Outcomes Framework, Expert Patient Programme,

    development of Community Matrons, national and local demographics. Another powerful

    driver for change is the following Public service agreement targets:-

To improve health outcomes for people with long term conditions by offering a

    personalised health care plan for vulnerable people most at risk.

To reduce emergency bed days by 5% by 2008, through improved care in primary care

    and community settings for people with long term conditions.

    1.4 Policy Development

Alternative models of care have been piloted in the UK during the last two years. A policy

    document Supporting People with Long Term Conditions was published in January 2005

    with supporting documents due Spring 2005 and a National Service Framework for Long

    Term Neurological conditions is due to be published in late 2005. The Department of Health

    has facilitated evaluation of the following models:

Castlefields Health Centre

    ? 15% reduction in unplanned admissions

    ? 31% reduction in hospital length of stay

    ? Total hospital bed days fell by 41%

    ? Significant savings

    ? Better patient and carer experience

    ? Improved integration of services

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 3

Evercare (USA)-

    ? 50% reduction in unplanned admissions without detriment to health

    ? Significant reduction in medications

    ? High patient satisfaction

NHS adapted Evercare

    ? 55-87% High risk population were not accessing District Nursing services

    ? 3% of the target population account for 30% unplanned admissions

    ? Many admissions are avoidable (urinary tract infections, dehydration)

    ? Polypharmacy issues

1.5 These studies have informed the policy direction, it is anticipated that the

    recommendations will be

    1. Further development of integrated approaches for the management of patients

    with long term conditions. With local models being developed informed by the

    Kaiser model of population management. It is important that clinicians are involved in

    decision making at all levels.

Targeting Populations ?Redesigning Processes ?Measurement of


    Level 3


    Level 2Specialist DiseaseHigh riskManagementpatients

    Level 1Supporting care

    70-80% of aAnd Self CareChronic disease pop

     Population Wide Prevention

Level 3 Highly Complex patients. As people develop more than one chronic condition (Co-

    morbidities), their care becomes disproportionately more complex and difficult for them, or

    the health and social care system to manage. This calls for case management with a key

    worker (often a nurse) actively managing and joining up care for these people.

Level 2 High Risk patients. Disease / care management, in which multidisciplinary teams

    provide high quality evidence-based care, following agreed protocols and pathways for

    managing specific diseases. It is underpinned by good information systems patient

    registries, care planning, and shared electronic health records.

Level 1 70 -80% of patients with a long term condition. With the right level of support many

    people can learn to be active participants in their own care, living with and managing their

    conditions. This can help them to prevent complications, slow down deterioration and avoid

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 4

getting further conditions. The majority of people with chronic conditions fall into this

    category so even small improvements can have a huge impact.

    2. Primary Care Trusts (PCT) will have a central role to play, working in

    partnerships with Local Authorities in developing a new strategic approach that

    moves towards planned proactive care the community where an acute response to

    a crisis is seen as a last resort.

    3. Plurality of service provision will be encouraged further development of

    voluntary sector provision and usage of the private sector.

    2.0 Implications for Hillingdon PCT

To achieve the stated aim there must be a move from the traditional model of care,

    described as a sickness care model episodic in nature and physician centric, to a chronic care model which has the following characteristics

    ? Care is proactive

    ? Delivered by a health care team

    ? Integrated across time, place and conditions

    ? Delivered in new ways group appointments, nurse clinics, telephone, internet, email,

    remote care technology

    ? Self Management support and responsibility an integral part of the delivery system

We therefore need to move from a reactive /episodic model to a planned /managed model of

    care. Changes in service provision across health and social care is essential to achieve this .

3.0 What needs to happen?

3.1 Understand the incidence of long term conditions locally A recent King‟s Fund

    Analysis of hospital admissions and frequent attendees described the age distribution

    11.7% aged 0 -17

    18.2% aged18 -39

    30.0% aged 40 -64

    18.6% aged 65-70

    27.4% aged 75 plus

The diagnostic clusters vary from PCT to PCT. Early work in Hillingdon on the analysis of

    patients having five or more admissions via A&E in a one year period, undertaken by the

    Urgent Care Network, suggests the diagnostic clusters to be mental health, COPD, CHD,

    Cancer, Alcohol / Drug misuse, and diabetes (List is not in a ranked order). Further work

    needs to be undertaken to ensure data quality is acceptable coding issues and cross

    referencing with community and primary care systems. A further information trawl will be

    required once risk stratification criteria are identified.

Data analysis demonstrates that the high risk population is wider than frail elderly with

    multiple complex problems. Many are younger with single conditions. Consequently we may

    require a variety of types of case management having undertaken further analysis of PCT


3.2 Describe the highest risk population and frequent hospital / health service

    users agree within the PCT a process for risk stratification. Methods have varied within the

    various models previously described; they have included predictive, functional impairment,

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 5

recent demand for resources, population or a combination. The Department of Health

    recommend the usage of the following criteria

    ? Two or more unplanned admissions within the last 12 months

    ? 4 or more prescribed medicines

    ? living alone/ recent bereavement

    ? the number of medical and other problems a patient has (Co-morbidity)

    ? recommendation by general practice, social care and/ or secondary care

    Having agreed the high risk population the PCT‟s first priority will be to develop a system

    of proactive case management.

    3.3 Design case management to fit local need The key principle of case management - a professional, usually clinical, case manager

    coordinating a care plan for an individual.

    The case manager may well be the future Community Matron (the role of the Community

    matron is to proactively and seamlessly plan a patient‟s journey through all parts of the

    health and social care system).

by 2008 there will be 3000 community matrons using case management techniques to

    care for around 250,000 patients with complex needs’. (The NHS Improvement Plan,

    DH 2004)

Community Matrons are likely to have 50 -80 patients with the most complex needs and who

    require clinical intervention as well as care co-ordination. They will work across health and

    social care services and the voluntary sector. Community Matrons can come from any

    branch of nursing. Matrons will “anticipate, co-ordinate and join up health and social care” (Supporting People with Long Term Conditions DH Jan 2005)

The key tasks of case management are case finding/ screening, assessment, care planning,

    implementing individual management plans, monitoring and review.

The challenge will be to combine intensive support for current high risk patients with an

    appropriate level of care and early warning systems for the next tier of severity.

3.4 Development of disease specific care management

    The provision of responsive specialist services using multidisciplinary teams and disease

    specific protocols and pathways for people who have more complex single or multiple

    conditions. ( example Falls service appendix 3)

Hillingdon PCT has developed a number of disease specific management guidelines

    examples are cardiovascular, diabetes, mental health and osteoporosis. Systems should be

    in place for the measurement of outcomes and feedback.

3.5 Development of support for self management

    The aim here is to provide education and support for people to enable them to take an active

    role in taking care of their own conditions and adopting approaches that prevent these

    conditions from getting worse and reducing the risk of getting further conditions.

New forms of provision of support have been developed in Hillingdon. These include the

    development of the Expert Patient Programme (appendix 2), educating patients to care for

    their specific conditions for example, diabetes support groups, medicines management

    collaborative, community development.

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 6

    Additional areas for consideration

    ? Diagnostics and monitoring close to home

    ? Development of appropriate and accessible information

3.6 Population wide Prevention

    Ensuring the opportunities and support are in place to make healthier life choices about diet,

    exercise and lifestyle particularly for those in disadvantaged groups and areas.

4.0 Recommendations

    1. PCT to establish a lead / long term condition Network Director (See appendix 1

    long term conditions :Health and Social care economy map)

    2. PCT to develop a system of proactive case management having agreed the criteria

    for determining the high risk population

    3. PCT to develop the role of the Community Matron

    4. PCT to review QMAS and clearnet data to fully understand the incidence of long term

    conditions locally and inform the determination of the high risk population.

    5. PCT to report on progress on managing Long Term Conditions

    6. PCT to continue to support the development of the Expert Patient Programme

    7. PCT to agree targets for the reduction in emergency bed days (PSA12a), the number

    of community matrons (PSA12b) and the number of patients managed by community

    matrons (PSA12c)


Appendix 1 - Long-term conditions: health & social care economy map

    Appendix 2 - Expert Patients Programme

    Appendix 3 - Update on Falls services in Hillingdon January 2005


    Long Term Conditions Compendium

    NHS Improvement Plan

    National Standards, Local Action

    Supporting People with Long Term Conditions

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 7

    Long-term conditions: health & social care economy map

    Appendix 1

    Network Director

     Primary Care Carers Community matrons information District nurses Social Services

     Expert Patients Voluntary sector Programme People with

     Long-Term Conditions


     Independent sector Management

     NSF leads

     Hospital (CHD, cancer plan, children, information

     diabetes, mental health, older people, renal)

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING) Date: 25 January 2005 Page No 8

    Appendix 2

Expert Patients Programme

    The Expert Patients Programme (EPP) is a DoH initiative that builds on the work of Arthritis Care and the Long Term Medical Conditions Alliance. EPP seeks to address the shift in disease patterns from acute to chronic disease. The objectives of the EPP are to enable people living with chronic conditions, in partnership with their health care professional, to become better able to manage their illness on a day-to-day basis, and to promote the most appropriate use of available health care.

    The EPP course runs over six weeks with a 2? hour session each week and, after the course, participants are encouraged to form ongoing support networks. The course no illness specific information and does not conflict with any existing treatment. The format of each course is identical and is delivered by non-medical tutors who have completed an EPP course and have a chronic condition. The course content is:

    ? Goal setting/action planning

    ? Problem solving

    ? Fitness and exercise

    ? Better breathing

    ? Symptom management cognitive techniques

    ? Fatigue management

    ? Nutrition

    ? Dealing with emotions

    ? Communication with family and healthcare professionals

    ? Making better us of medication

    ? Living wills and power of attorney

    ? Working with your healthcare professional

    The content enables people to develop the confidence and skills to effectively manage their illness.

Measured outcomes from the programme include:

    ? Improved life control and satisfaction

    ? Reduced severity of symptoms and decrease in pain

    ? Better relationships with healthcare professionals

    ? A reduction in inappropriate use of services

    ? Improved self-efficacy

    ? Improved us of health promoting techniques

    ? Reduced number of visits to health professionals

    ? Improved psychological health

    Courses are delivered by two tutors and are held in community settings. Tutors are assessed regularly to ensure the governance of course delivery.

    The EPP can be accessed through self-referral or by clinician referral. There is no upper age limit for the course but applicants must be over eighteen and have a chronic condition (any condition that will not resolve itself.)

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 9

Appendix 3

    Update on Falls services in Hillingdon

    January 2005

Summary of Targets for falls services: (NSF older people)

April 2003

    Local health providers (health social and independent providers should have audited

    procedures and put in place risk management procedures to reduce risk of people falling.

April 2004

    The HIMP and other plans developed with Local Authority and independent sector partners

    should include the development of an integrated falls service.

April 2005 All local health and social care systems should have developed this service

1. Context

1.1 The development of falls services in Hillingdon has been overseen by the Joint Strategy

    group for Older People; given it is a key target within the NSF. This has enabled a multi

    agency approach to planning and development of a wide base of services spanning from

    prevention, through to urgent care.

    th1.2 Falls is the 6 highest cause of mortality in people over 65, with an estimated spend per

    PCT of ? 1.7 million, including drugs, acute care and long term social care. NICE guidance

    published in November 2004 provides a clear evidence based framework for the

    development of integrated falls services.

    The key principles are:

    ? Risk assessment to identify and manage risk factors

    ? Multi factorial assessment following a fall or to prevent a fall

    ? Interventions including: Home safety, medication withdrawal, cardiac pacing,

    strength and balance training, participation in falls prevention and rehabilitation

1.3 The primary aims of falls services in Hillingdon is to:

    ? Enable a reduction in people falling (by a minimum of 15 %) through use of a falls

    prevention service and active management of factors that cause falls.

    ? To reduce the number of falls in bed based services including mental health, acute

    and intermediate care beds

    ? To reduce the number of falls related A&E attendance & admissions by the

    development of alternative pathways and services. (Baseline is approx 720 falls

    admissions per yr and 1,500 A&E attendances)

    ? To increase the number of fallers/#NOF who can live home and self manage, and

    reduce the number needing extra care help or admission to residential /nursing


    ? To reduce psychological trauma following a fall so that older people have more

    opportunities to remain independent with access to support, lifestyle advice &

    confidence building

    Hillingdon Primary Care Trust Board (PART ONE PUBLIC MEETING)

    Date: 25 January 2005 Page No 10

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