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Managing Multimorbidity in PracticeDr.Kevin Gruffydd-Jones    TAYSIDE CENTREBox SurgeryWilts.                             ...
Why bother?• 15.4 million people in England with at least  one long –term condition( DoH 2012)• Estimated by 2025 increase...
Why bother?   More Likely to :   Die Early   Be Admitted to Hospital   Poor Quality of Life   Multiple drugs   Poor adhere...
Patient-Centred Management of Stable COPD in Primary Care                                                            ALL P...
Co-Morbidities in Practice                Barnett et al Lancet 2012Co-Morbidities in Practice                Barnett et al...
Co-Morbidities in Practice COPD 3.5 co-morbidites (v 1.8) Sin et al ERJ 2006                           Barnett et al Lance...
Patient-Centred Management of Stable COPD in Primary Care                                   All PATIENTS        Smoking ce...
What evidence have we got so                far?•                  NOT A LOT!Managing patients with multimorbidity:systema...
What evidence have we got so             far?• 10 studies looking at interventions in  primary care settings• 8 out of 10 ...
National Survey of Multi- morbidity in clinical practice with COPD as an examplar                    Dr Shoba Poduval     ...
Survey•   Open 29.11.12 - 8.2.13•   Thirty four responses•   Thirteen reviewed- themes•   Five case studies•   Other Pract...
Motives• QoF• PBC/CCG funding• Improving patient experience   Patient selection & invitation• Disease registers• Disease s...
Staff• Practice team: GP’s, Nurses, HCA’s,  admin staff• Community team: District Nurses,  Community Nurses, Social Servic...
Outcomes•   Patient and staff satisfaction•   More appointment time available•   Medication adherence•   Reduced A&E atten...
Discussion• What is your experience of managing  multimorbidity?• Challenges?• Suggestions? So What do we do in Practice? ...
16
CHALLENGES•   Deciding on the co-morbidities•   Content and Integration of Templates•   Management of Housebound•   Medici...
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Breakout 3.2 Managing Multimorbidity in Practice - Dr Kevin Gruffydd-Jones

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Breakout 3.2 Managing Multimorbidity in Practice - Dr Kevin Gruffydd-Jones
Box Surgery Wilts
Member PCRS(UK)
Respiratory Lead RCGP
Member of NICE COPD
Guidelines Committee and
Asthma/COPD Clinical
Standards Committees
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

Published in: Health & Medicine
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Transcript of "Breakout 3.2 Managing Multimorbidity in Practice - Dr Kevin Gruffydd-Jones"

  1. 1. Managing Multimorbidity in PracticeDr.Kevin Gruffydd-Jones TAYSIDE CENTREBox SurgeryWilts. BOXMember PCRS(UK)Respiratory Lead RCGPMember of NICE COPDGuidelines Committee andAsthma/COPD ClinicalStandards Committees. Multimorbidity v co-morbidity • “Multi Morbidity” co-existence of 2 or more diseases in one person (Mercer et al Family Practice 2009.) • “Co-morbidity” Presence of other diseases in a person with a reference disease 1
  2. 2. Why bother?• 15.4 million people in England with at least one long –term condition( DoH 2012)• Estimated by 2025 increase of 42%•• 78% of all GP consultations• 70% Health and Social Care Budget, Why bother?• 60% patients in Scottish Study 2 or more conditions . More people under 65 than over 65 (Mercer BMJ 2012)• Canadian Study 69% 18-44, 93% 45-65, 98% > 65(Fortin et al 2007)• Associated with deprivation. Onset multimorbidity 10-15 years earlier in developing countries(Smith BMJ 2012) 2
  3. 3. Why bother? More Likely to : Die Early Be Admitted to Hospital Poor Quality of Life Multiple drugs Poor adherence Susan Smith BMJ 2012http://www.pcrs-uk.org/resources/copd_guidelinebooklet_final.pdf 3
  4. 4. Patient-Centred Management of Stable COPD in Primary Care ALL PATIENTS Smoking cessation advice Exercise promotion Patient education/self management Pneumococcal vaccination Assess co-morbidity, Annual influenza vaccination ASSESS BMI: Dietary Advice >25 Specialist Dietary Referral if BMI <20 FUNCTIONAL SYMPTOMS? EXACERBATIONS? HYPOXIA? HOLISTIC LIMITATION ? CARE BREATHLESSNESS MRC score > 3 (Oral steroids/antibiotics/ Oxygen saturation Check social Hospital admissions) < 92% at rest in air) SupportShort acting bronchodilators Optimise pharmacotherapy (e.g. carers and (see algorithm) FEV-1 < 30%(beta agonist/anticholinergic) benefits)for relief of symptoms. Predicted Optimise pharmacologic Treat co-morbidities. therapy Offer pulmonary Consider PalliativePERSISTENT SYMPTOMS rehabilitation therapy or secondarySee pharmacotherapy Care referral forAlgorithm Resistant symptoms Screen for Discuss action plans iPRODUCTIVE COUGH anxiety/depression including use of standbyConsider mucolytics Refer to specialist oral steroids and antibiotics Refer for oxygen Palliative care teams assessment For end-of-life care. COPD is not just a disease of the lungs HEART FAILURE (20%) Cachexia/ Osteoporosis muscle wasting (11%-38%) 40% osteopenic in Depression “TORCH” (25%patients Metabolic syndrome FEV-1 <50%) (50% with 1 or more features) Lung function is poorly related to the impact of disease upon the patient(Paul Jones.PCRJ 2011). 4
  5. 5. Co-Morbidities in Practice Barnett et al Lancet 2012Co-Morbidities in Practice Barnett et al Lancet 2012 5
  6. 6. Co-Morbidities in Practice COPD 3.5 co-morbidites (v 1.8) Sin et al ERJ 2006 Barnett et al Lancet 2012Patient-Centred Management of Stable COPD in Primary Care All PATIENTS Smoking cessation advice Exercise promotion Patient education/self management Pneumococcal vaccination Assess co-morbidity Annual influenza vaccination ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20 HOLISTIC CARE Check social Support (e.g. carers and benefits) Treat co-morbidities. Consider Palliative therapy or secondary Care referral for 1. FEV-1<30% Resistant symptoms 2. Recurrent Hospital admissions 3. for acute COPD. Refer to specialist 4. Housebound Palliative care teams 5. BMI <20 For end-of-life care. 6. On LTOT Would you be surprised if this patient died within the next year? (6 months) 6
  7. 7. Patient-Centred Management of Stable COPD in Primary Care All PATIENTS Smoking cessation advice Exercise promotion Patient education/self management Pneumococcal vaccination Assess co-morbidity Annual influenza vaccination ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20 HOLISTIC CARE Check social Support (e.g. carers benefits) Treat co-morbidities. How does this fit in everyday management? 7
  8. 8. What evidence have we got so far?• NOT A LOT!Managing patients with multimorbidity:systematic review of interventions inprimary care and community settingsBMJ 2012; 345 doi:http://dx.doi.org/10.1136/bmj.

Susan M Smith,associate professor of general practice1, Hassan Soubhi, adjunctprofessor of family medicine2, Martin Fortin, professor of familymedicine2, Catherine Hudon, associate professor of familymedicine2, Tom O’Dowd, professor of general practice3 8
  9. 9. What evidence have we got so far?• 10 studies looking at interventions in primary care settings• 8 out of 10 studies US• ORGANISATIONAL(Multidisciplinary team, education , drug review(including pharmacist) SELF MANAGEMENT : education , structured self-mangement What evidence have we got so far?• Results mixed.• Some evidence of improvements in specific areas e.g medicines management• Results ? Better when specific co- morbidity looked at and when look at functional limitation.• Paucity of economic studies. 9
  10. 10. National Survey of Multi- morbidity in clinical practice with COPD as an examplar Dr Shoba Poduval Clinical Support Fellow and First5 GP Survey• 7 point questionnaire uploaded to survey monkey – What did you do? How did you do it? Why? What prompted you? – Overall impact -how this benefits patients, staff and the organisation – Lessons learnt, what went well? What didn’t work well? Advice for others 10
  11. 11. Survey• Open 29.11.12 - 8.2.13• Thirty four responses• Thirteen reviewed- themes• Five case studies• Other Practices of note- telehealth Preliminary ResultsThemes • Outcomes• Motive • Evaluation• Patient selection & • Challenges invitation• Organisation• Staff• Housebound patients 11
  12. 12. Motives• QoF• PBC/CCG funding• Improving patient experience Patient selection & invitation• Disease registers• Disease severity stratification• Specific patient selection criteria 12
  13. 13. Staff• Practice team: GP’s, Nurses, HCA’s, admin staff• Community team: District Nurses, Community Nurses, Social Services, Pharmacists• Secondary Care Housebound• Visits by GP’s & Community Matrons• On-going support from Community Matron & Social Services 13
  14. 14. Outcomes• Patient and staff satisfaction• More appointment time available• Medication adherence• Reduced A&E attendance• Projected savings Challenges• Training• Organisation- time• Resources- templates• Funding 14
  15. 15. Discussion• What is your experience of managing multimorbidity?• Challenges?• Suggestions? So What do we do in Practice? Long term condition Clinics IHD/Diabetes/ Heart Failure etc. Chronic Care Model of Wagner (Proactive structured care, supportive self manage Care Planning 15
  16. 16. 16
  17. 17. CHALLENGES• Deciding on the co-morbidities• Content and Integration of Templates• Management of Housebound• Medicines Management Review• Stratifying Risk and use of Community Teams. 17

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