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Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Cont...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Intr...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?The ...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Find...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities? Cas...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Key ...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?    ...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Staf...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Chal...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?The ...
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Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Poin...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Refe...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Ackn...
Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?22
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Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities
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Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities

  1. 1. Royal College of NHS General Practitioners NHS Improvement LungCANCERDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - LungManaging multi-morbidity in practice…what lessons can be learnt from the care ofpeople with COPD and co-morbidities?
  2. 2. Endorsed by: Royal College of General PractitionersThe Royal College of General The Primary Care Respiratory Education for Health is thePractitioners is a network of Society UK (PCRS-UK) is the worlds leading charity tomore than 45,000 family UK-wide professional society focus on the education ofdoctors working to improve dedicated to meeting the health professionals as a keycare for patients. We work to vision of ‘optimal respiratory factor in improving patientencourage and maintain the care for all’. Our mission is health and quality of life.highest standards of general to give every member of the Our mission is to take action,medical practice and act as primary care practice team educate people andthe voice of GPs on the confidence to deliver transform lives worldwide.education, training, research quality respiratory care and We are a specialist providerand clinical standards. improve the quality of life of pioneering cardiovascular for patients with respiratory and respiratory education disease. and training courses, products and qualifications.
  3. 3. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?ContentsManaging multi-morbidity in practice… whatlessons can be learnt from the care of people withCOPD and co-morbidities?Introduction 4Findings from sites 6• Survey method 6• Case study 1: Vauxhall Practice, Liverpool 7• Case study 2: Yellow Practice, Govan Health Centre, Glasgow 8• Case study 3: Leckhampton Surgery, Cheltenham 9• Case study 4: Woodbrook Medical Centre, Loughborough 10• Case study 5: Birtley Medical Group, Gateshead 11• Case study 6: Phoenix Medical Practice, Bradford 12Key themes 13Challenges 16The way forward 17Conclusion 18Points to consider – developing structured reviews in practice 19References 20Acknowledgements 21 3
  4. 4. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?IntroductionThe case for managingmulti-morbidity Table 1: Co-morbidity of 10 common primary care conditions in 314 Scottish general practices1With an increasingly ageingpopulation comes the challenge ofhow to deal with people withmulti-morbidity (i.e the presence oftwo or more long term conditions inone person). Although theprevalence of multimorbid conditionsrises with age, a study of 314 Scottishgeneral practices showed absolutenumbers to be higher in the under 65age group.1 Furthermore, a Canadianstudy suggested that multimorbidityis the norm rather than the exceptionwith 69% patients aged 18-44having multimorbidity and 93%patients aged 45-64.2People with multimorbidity are morelikely to die at an earlier age, morelikely to be admitted to hospital, havea poorer quality of life and are more There is therefore an increasing need COPD and co-morbiditylikely to be prescribed multiple drugs to organise care around the patient as an exemplarwith consequent poor adherence.3 and not the disease, taking into Chronic obstructive pulmonaryThis suggests that there is scope to account his or her multiple physical disease (COPD) is a long-termimprove management and outcomes and psychosocial conditions. 4 condition with a high prevalence (anfor these patients. Traditionally, estimated three million people indisease management guidelines and A systematic review of interventions England)5 and with a high number ofpatient pathways have been devised for people in primary care and co-morbidities. Table 1 shows thearound single disease entities. This community settings which targeted prevalence of co-morbidities ofhas been encouraged by the demise multi-morbidity indicated that there significant long-term conditions inof the generalist in secondary care was limited research evidence the Scottish general practiceand the development of super- available.3 However, the review multi-morbidity study, and shows thatspecialties. However, this disease- indicated that interventions targeted people with COPD over the age of 65centred approach tends to either at specific combinations of had a mean of 4.5 co-morbidunderestimate the effect of common conditions, or specific conditions shown in the table.1 Aspsychosocial factors influencing the problems for patients with multiple such, the organisation of care forpatient’s health and encourages the conditions, may be more effective. people with COPD and itsdevelopment of multiple treatment co-morbidities has the potential to beregimes with increased potential for an exemplar for the organisation ofadverse drug interaction and poor care for people with multi-morbiditiesadherence. in general.4
  5. 5. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?The Wagner chronic care model ofstructured care6 has identified four Figure 1: Patient centred management of stable COPD in primary care8key elements which are likely to have ALL PATIENTSa major impact on the quality and SMOKING CESSATION ADVICE EXERCISE PROMOTIONeffectiveness of care. These PATIENT EDUCATION/SELF MANAGEMENT PNEUMOCOCCAL VACCINATION ASSESS AND TREAT COMORBIDITY ANNUAL INFLUENZA VACCINATIONelements are: ASSESS BMI: DIETRY ADVICE >25 SPECIALIST DIETRY REFERRAL IF BMI <20• the promotion of self-management, SYMPTOMS? FUNCTIONAL EXACERBATIONS? HYPOXIA? HOLISTIC CARE LIMITATION?• a comprehensive system to support Breathlessness MRC score > 3 Oral steroids/ clinical management, antibiotics/hospital Short acting Optimise• evidence-based support for bronchodilators (beta pharmacotherapy admissions agonist/anticholinergic) (see algorithm) decision making, and for relief of symptoms. Offer pulmonary Optimise pharmacologic therapy Oxygen saturation < 92% at rest in air) Check social support (e.g. carers and benefits)• the use of clinical guidelines. PERSISTENT SYMPTOMS See pharmacotherapy rehabilitation Discuss action plans FEV-1 < 30% (Treat co-morbidities). Algorithm Screen for including use of standby Predicted anxiety/depression oral steroids and Consider palliative therapy antibiotics Refer for oxygen or secondary care referralThe 2010 NICE COPD Guidelines5 PRODUCTIVE COUGH Consider mucolytics assessments for resistant symptomsand international GOLD COPD Refer to specialistGuidelines7 have increasingly palliative care teams for end-of-life care.recognised the need to assess co-morbidities when carrying out routine Source: Primary Care Respiratory Society UK, 2010assessment of the patient with COPD.The Primary Care Respiratory Society-UK (PCRS-UK) have adapted the NICECOPD Guidelines for primary careand advocate a patient-centred This includes learning about planningapproach to COPD assessment and ahead, organisational issues,management8 including the identifying the right patients andassessment of co-morbidities. Figure evaluating the impact of change.1 shows an algorithm summarising As such, it will be of help to all thosethis patient-centered assessment. interested in improving the way careHowever the guidelines fall short of is organised in their own area forhow to organise care for these patients with multi-morbidity.patients.This document summarises the Kevin Gruffydd-Joneslearning from a project to find out GP Box Wiltshire , Respiratory Leadhow general practices in the United RCGPKingdom have risen to the challengeof organizing chronic care of patients Shoba Poduvalwith multimorbidity in practice, using GP Islington, London and Clinicalthe exemplar of COPD and its Support Fellow RCGPco-morbidities. It provides practicalexamples of approaches that have Correspondence tobeen tried, key learning points about Dr. Kevin Gruffydd-Joneswhat works and why, and Email: Kevin.Gruffydd-Jones@gp-suggestions for the way forward. J83013.nhs.uk 5
  6. 6. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Findings from sitesSurvey methodA simple seven item questionnairewas developed by themultidisciplinary project committeewhich included questions aboutpractice demographics, how and whysystems for managing COPD patientswith co-morbidities were developed,the impact and any lessons learnt.The questionnaire was uploaded toSurvey Monkey and publicisedamongst the networks of the RoyalCollege of General Practitioners,NHS Improvement, the Primary CareRespiratory Society UK andEducation for Health. The survey wasopen from the 29 November 2012to 8 February 2013.Over thirty sites responded to thecall for examples of effectivemanagement of multi-morbidityin COPD patients. Many of therespondents described systems formanaging COPD withoutco-morbidities and other practicesdid not wish to be contacted further.Six case studies were chosen by theauthors which were thought torepresent the various approaches thatpractices used to tackle the problemof chronic disease management ofpeople with COPD and itsco-morbidities.6
  7. 7. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities? Case study 1: Vauxhall Primary Health Care, Liverpool Vauxhall Primary Health Care (VPHC) is an urban practice in Liverpool with a list size of 6,000 patients and a team including GPs, practice nurses and a health care assistant. A quality improvement project has been ‘‘ The consultation was an expert generalist needs assessment, based on the principle of a person-centred assessment of what was wrong and what intervention was needed. In practice, much of the decision making related to demedicalisation... reducing the running here for three to four years since ’’ the practice obtained funding from burden of care. neighbourhood cluster efficiency savings for 1.5 days/week of GP time to address the question: What are the challenges? Key learning points With the next stages of this work being • Identify your key ‘at-risk’ group that is planned, the following challenges have most likely to benefit.“How can we improve the been identified: • Bear in mind the importance of holistic care of housebound • Who are the next most important target care - 63% of patients were found groups? Care home residents? New to have needs not met by existing patients with complex patients with multimorbidity? Patients chronic disease management or needs registered at with acute complex needs? medication review processes and • Limits to funding due to competing identifying these needs was difficult VPHC?” priorities. from routine collected data alone. • With limited time available, the team Assessment by an experienced GP, with What do they do? will need to be clear about how best to an ‘off-protocol’ patient-centered First of all the practice established a use community matrons and GPs, for approach was found to be more useful. register identifying patients at need, example focusing GP effort on the less • Make use of your community teams. targeting first those who were straightforward cases such as those • Work through how much clinical time housebound with more than one Quality where diagnostic issues are dominant. is required and how you will find or & Outcomes Framework (QoF)-registered fund it. disease, multiple medications and unplanned admissions in the last year. We are starting to make greater use of community Patients were contacted by letter. All visits matrons and also community pharmacy. Reserving GPs were carried out by GPs who completed an assessment, involving a review of the for the less straightforward cases...what we are still notes - including tidying up problem lists; struggling with is how to predict who those are. But often medication review; care assessment it is where the DIAGNOSTIC issues are dominant. (where possible involving carers themselves); assessment of level of need Dr Joanne Reeve, Vauxhall Primary Health Care (low, medium or high) and a documented plan of care. Table 2: Feedback Summary What did they achieve? Recorded data was audited and Patients/carers For some, surprise/suspicion/concern that doctor has visited experiences of staff, patients and carers for review, unsolicited by patient. reviewed. Results from initial data From family/carers, support for opportunity for time for full available indicated a lack of impact on assessment/discussion especially re medication. admissions but a reduction in prescribing. Data showed that inappropriate Staff at care Positive impact of proactive review of patients, including medication was stopped in 54 patients homes tidying up/rationalising medication. out of 101 patients, due to a long-term view being taken about safety. Staff at VPHC Useful impact of reviewing the patient’s list of problems, Informal feedback was generally positive, medication reviews etc; protected time for visits for complex especially from staff and carers (see patients valuable. table 2 7
  8. 8. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case study 2:Yellow Practice, Govan Health Centre, GlasgowYellow Practice is an inner city What has been achieved?practice based in a health centre with Patients have provided positive feedbackthree other Practices in Glasgow. It and comments on how much better thehas a list size of 4,000 patients, four service is now. Fewer appointments areGPs and two practice nurses. taken up as most of the conditions covered involve similar measurements andWhat do they do? lifestyle issues. Receptionists also find itFor three years the practice nurse has easier to book one appointment for theorganised an ‘Annual Health Review annual review.Clinic’ for patients with multiple chronicdiseases. Patients get a half hour The team has also found this system isappointment with the practice nurse, better in relation to the practice’s QOFduring which conditions including targets and Locally Enhanced Service (LES)diabetes, heart disease, kidney disease, requirements, as everything is tackled athypertension, heart failure, asthma, once and it is easier to monitor targetschronic obstructive pulmonary disease and results.(COPD) and stroke can be reviewed. Ifmore time is needed a further What were the challenges?appointment is booked, and if necessary • The lack of recall coding on the EMISa six monthly review can be arranged. electronic records system. • Evaluating cost benefits.Patients are invited by letter (or textmessage if they have a mobile phone) What were the key learning points?and administrative staff are aware they • Create a code in EMIS for chronicneed to make thirty minute appointments disease management review - it is timefor these reviews. consuming to code everyone with that code but once done it is very useful.A second practice nurse is employed to • When to time the recall - the team atcarry out annual health checks for the Yellow Practice tried making thehousebound, and residents of care patient’s annual review in the month ofhomes. These patients are seen annually, their birthday but for those who didntsix monthly or more often if required. respond straight away and were late itNo other community teams are involved didnt work. So reviews are nowapart from the podiatry services that visit booked according to when the patientthe housebound diabetic patients at was last seen. This took time and efforthome and review diabetic patients who to organise but now works very well.have been identified as having high ormoderate diabetic foot disease.Why did they do it?The practice nurse instigated this way ofmanaging patients with multiple chronicdisease because patients reported thatthey were tired of being invited fordifferent reviews at different clinicsseveral times a year.8
  9. 9. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case study 3:Leckhampton Surgery, CheltenhamLeckampton Surgery is an urban What did they achieve?Practice of 12,000 patients, nine Attendance is very good, and patientdoctors, five Practice Nurses and satisfaction has increased due to onlythree HCA’s. having to attend surgery once a year for review. In addition, more appointmentsWhat do they do? are available for the nursing team.The Leckhampton Surgery runs a ‘one- ‘‘stop’ clinic for review of patients withmultiple chronic diseases. Each conditionis given 20 minutes plus extra time ifneeded. Patients are seen by a registerednurse who has skills and qualifications in My advice is plan the clinic carefully. Work hard on thechronic disease management, COPD, wording of the invite letter, keep it simple. PhoneAsthma, Heart disease and diabetes. Sheis assisted by a health care assistant who patients to remind them of the appointment - its a big ’’completes all the clinical measurements chunk of time if they do not attend.beforehand such as spirometry, bloodsand diabetic foot checks, having Sharon Lamden, Lead Practice Nurse,completed National Vocational Leckhampton SurgeryQualification (NVQ) training. The nurse isa prescriber but GPs are involved wherenecessary. Staff training has been fundedby the practice and the pharmaceuticalindustry.Patients are invited by letter and phonedor text messaged the week before toremind them of their appointment.Housebound patients are visited by apractice nurse at request from a GP, or bythe GPs themselves. Community staff areasked to contribute to the review ofhousebound patients but it is found thatthey have very little time to spend onthese reviews and are not trained inchronic disease management of multipleconditions. 9
  10. 10. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case study 4:Woodbrook Medical Centre, LoughboroughWoodbrook Medical Centre is anurban 9,000 patient practice inLoughborough. There are six doctors,three nurses, a health care assistantand phlebotomist.What do they do? ‘‘ The multiplicity of long term conditions borne by many of our patients demonstrates the difficulties involved in obtaining optimal outcomes for these conditions both individually and collectively; focusing on what the patient wishes to achieve will be more useful inWoodbrook planned to set up a one stoplong term conditions clinic. They applying therapies rather than relying on singleidentified patients from the electronic condition guidelines many of which will haverecords system with long term conditionssuch as chronic obstructive pulmonary conflicting objectives and recommendations. Thedisease, hypertension and diabetes and future lies in navigating these guidelines guided byrecorded the number of co-morbiditiesthe patient had. Figure 2 compares the the patient’s wishes and moving away from strictly ’’number of selected co-morbidities seen targeted control.with each condition. Dr Dermot Ryan, Woodbrook SurgeryDisease severity was also stratifiedaccording to markers such as ForcedExpiratory Volume and Medical Research Figure 2 : Number of Co-morbidities with reference conditionCouncil (MRC) Score for breathlessness. (on y axis) in Woodbrook Surgery, Loughborough.Patients with two or more co-morbidities CKDwould be taken through the process Epilepsysummarized in the flowchart shown in Heart FailureFigure 3. Stroke COPD HypothyroidismWhat were the challenges? CHDThe practice organized a three hour team Diabetesmeeting with all lead clinicians where a Asthma Hypertensiondetailed notes review of six patients was 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100undertaken. Although some savings were Hyper Asthma Diabetes CHD Hyperth COPD Stroke Heart Epilepsy CKDprojected in terms of prescribing tension yroidism Failure With main condition and 5 others 2 0 2 1 1 1 2 2 0 1rationalization and reduction in With main condition and 4 others 23 7 14 11 9 12 10 7 2 20appointments requested, they were With main condition and 3 others 62 28 43 45 19 23 17 21 1 57 With main condition and 2 others 176 60 115 76 32 37 37 28 4 95unable to progress further due to a lack With main condition and 1 other 369 111 194 91 66 67 59 18 16 87 521 504 147 73 109 58 32 4 35 2of funding for the extra clinical time that No. of patients - just 1 conditionwas needed.What were the key learning points? Figure 3 : Flow chart of organisation of care for patients• Resources need to be identified to fund with two or more co-morbidities in Woodbrook Surgery extra clinical time to get the project under way. Patient 2+ Identify blood Go to patient Send out invitation Perform bloods Notes for review tests as required summary to letter for blood and collect questionnaires by clinical pharmacist• A project manager is needed to create a co-morbidities for disease ensure all tests and monitoring or co-morbidities questionnaire Perform questionnaires Collection of bloods timetable and to keep the process QOF have tests with appointment if not completed and questionnaires required moving forward. Inform will be invited for review in three weeks Annual review Patient phoned 24 Review appointment GP nurse specialist Follow up as needed with actions hours prior made note review Reauthorise Forward diary for next review prescriptions10
  11. 11. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case study 5:Birtley Medical Group, GatesheadBirtley Medical Centre is an 80% What did they achieve?urban and 20% semi-rural practice Patients report greater satisfaction withwith a list size of approximately the new approach.14,500 in Gateshead, County Durham. ‘‘For 8-10 years the nursing team havebeen running a Better Health Clinicfor review of patients with chronicdiseases and co morbidities. People have expressed their appreciation of theWhat do they do? one stop shop approach, particularly because there ’’Patients are seen in a Better Health Clinic is a significant amount of interconnectedness.appointment of thirty minutes with asenior practice nurse or nurse practitioner Liz Bryant, Nurse Practitioner, Birtley Medical Group(depending on their co-morbidities). Allthe nurses who are involved have at leastdiploma training in the illnesses reviewed. What were the challenges?Patients are informed of the need for • Training staff to an adequate level totheir review by a note on their meet the requirements of the clinic.prescriptions. They are then asked to • Organising appointments so thatbook in for appropriate tests (such as enough time is allowed for review.bloods and spirometry) with a health careassistant and the Better Health Clinic Key learning pointsappointment is made with them for one • Investment in nurse recruitment andto two weeks later. Making the high quality training is essential, and itappointment with the patient has been is important to ensure that staffhelpful in improving attendance rates complete enough regular consultationswhich have been good. to keep up their skills. • Allow enough time for the review byHousebound patients are seen by GPs, making sure the blood tests andpractice nurses and community matrons spirometry are planned and executedas appropriate. in advance. 11
  12. 12. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Case study 6:Phoenix Medical Practice, BradfordPhoenix Medical Practice in Bradford, What have they achieved?West Yorkshire, has a patient base of A health economic evaluation of 193,600 patients and has been patients using the care planning approachchampioning the concept of care was published in the Health Serviceplanning with patients with Journal in 20109 This showed in amulti-morbidity under the direction reduction in health service contacts fromof Dr. Shahid Ali. This has centred on 529 to 246 in the 12 months pre anddiabetes, but includes COPD and post care planning, a reduction inother long-term conditions. outpatient contacts and a reduction in overall health costs.What do they do?40% of the practice patients had a long- What were the key learning points?term condition, of which 25% had two or The experience of being in control andmore. These patients were invited to making independent decisions is highlyattend appointments for a care planning motivating for patients. The care planningconsultation. Using an integrated long approach has been further piloted byterm condition template the patients, in other practices in West Yorkshire. Patienttheir own words, record the issues that empowerment is being further enhancedare important to them and how these by electronic sharing of data includingimpact on self-caring and setting self- goal setting via the internet or via smartdirected goals (e.g. giving up smoking). phones.Capturing this information ensures thegoals are relevant to the patient andmeans the patient can relate back tothem regularly. A follow up appointmentis made to assess progress against thesegoals.What were the challenges?There is a need for practice meetings tochange the culture of chronic diseasemanagement towards patient –centredand supported self-management.There is also a need for training on themulti-disease templates.12
  13. 13. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Key themesFindings from the survey suggest that 1. MOTIVATION TO ORGANISE At one practice, a telehealth systemwhilst practices have started to MULTLI-MORBID REVIEWS using joint management plans issuedimplement systems which co-ordinate Some practices identified optimizing by the local Community Partnershipthe organisation of care of people performance under the Quality and Trust enabled patients to self-managewith COPD and its co-morbidities Outcomes Framework (QOF) as the their symptoms over a trial period ofthese systems are in their infancy and main purpose for developing a three months.there has been little evidence of system for managing patients withformal evaluation. This conclusion multiple problems, due to the A key to successful organisation wasmust be tempered by the fact that opportunity to complete all reviews prior planning by multidisciplinarythere was a relatively low response and templates at one consultation. members of the practice teamrate to the request to complete thesurvey. Some practices utilised Practice – 3. TELEHEALTH & TECHONOLOGY Based Commissioning (PBC) or other Few practices provided informationThere may be several reasons for this: sources of funding to develop ideas on using telehealth or technology to• Practices have not organised for new systems, and others were support management of co-morbidity multi-morbid care around COPD. motivated by the need to increase in COPD or in multi-morbidity There is anecdotal evidence that patient satisfaction with the way their generally. Furlong Medical Practice in practice systems have been built up conditions are managed. Stoke on Trent, described how with ischaemic heart disease or telehealth can enhance patient diabetes as the reference disease. 2. ORGANISATION engagement in managing their COPD• General practices are under a lot of Nine of the thirteen practices who (see box on page 14 for details). workload pressure at present, as provided additional information used Nurses and patients have loved the evidenced by surveys from the the concept of a nurse-led ‘one stop system and it is being adopted more British Medical Association and so clinic’ reviewing multiple conditions widely and extended to other response rates to surveys may not in one consultation. Consultations conditions. be optimum, especially when sent tended to be structured around in a period around Christmas. COPD and ischaemic heart disease/ Successful implementation requires heart failure rather than other engagement of the whole practiceIn spite of these limitations several co-morbidities. Most of the nurse-led team in the initiative throughthemes emerged from those who clinics involved a thirty minute communication, incentives andresponded to the survey: appointment with measurements training, and ensuring that there is a such as spirometry and bloods clear and consistent approach to organised in advance. One practice identifying and recruiting appropriate used only fifteen minute patients to the service. appointments but found this challenging, especially as QoF data needed to be collected for all conditions using existing templates. 13
  14. 14. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities? 4. PATIENT IDENTIFICATION Telehealth in COPD management AND RECRUITMENT Furlong Medical Practice, Stoke on Trent, adopted a Clinical Most practices identified patients Commissioning Group (CCG) funded Florence mobile phone texting from their disease registers, with one service in January 2012 to enhance patient engagement in their COPD using the patient’s birthday month management. They identified patients on the COPD register whose as the month of their review. All clinical management could be improved and who could be given more practices used written letters to autonomy. Specific patient selection criteria were used, including invite patients to their review, with evidenceof one or more of the following: one phoning patients a week before their appointment to remind them. • excessive use of inhalers Some practices also used text • breathlessness on exertion messaging for patients who had • productive sputum mobile phones. • one or more exacerbations of COPD in last 12 months • attended practice frequently in previous year for respiratory reasons, The wording of the letter or message having been prescribed two or more courses of antibiotics was identified as an important • been admitted to hospital with exacerbation of COPD in previous year factor, as it influenced patient • attended Accident & Emergency, walk in centre, out of hours service anxiety and attendance rate. One with exacerbation of COPD/chest infection – in previous 12 months. practice described inviting patients who were not engaging up to three A joint management plan is agreed between patients and the practice times by letter, but if they did not nurse which is supported by a written leaflet. Patients take home a wish to receive help they were not pulse oximeter, thermometer, weighing scales and their rescue forced to take part but exempted for medication. They then receive daily texts asking about sputum colour that year. and oxygen saturations. Depending on sputum colour, they are asked if they feel unwell, and if so, are asked to take their temperature. If their 5. STAFF temperature is >37.5C, they take rescue medication according to their The majority of the practices ran agreed joint management plan. clinics led by practice nurses. Some practices had nurse prescribers to Clinicians monitor patients’ readings twice a week. There is a monthly modify medications but in other text enquiry about patient experience and the programme is run over cases medications were reviewed three months. There is an evaluation form at the end of the programme by GPs after discussion with the and good patient self-care literature is given to patients to supplement practice nurses. their learning from the programme. Two practices also used junior The practice believes telehealth enhances the care they deliver and nurses and health care assistants offers patients an enormous advantage in understanding their for spirometry, blood tests and condition, thus making them more likely to comply with any agreed diabetic foot checks. joint management plan. “Realise the potential of telehealth for enhancing quality of delivery of patient care and trial it in your team.” Professor Ruth Chambers, Furlong Medical Practice14
  15. 15. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Staff training was highlighted as an 6. HOUSEBOUND PATIENTSimportant issue. Most practices had There was a range of care modelsnurses with qualifications in chronic used to manage housebounddiseases. In some practices, nurses patients or patients with complexhad to be trained in chronic disease needs. At one end of the spectrummanagement or new nurses there was integrated team approachemployed. The cost of this was with initial review by a communitybalanced against the savings in matron or GP, and subsequentnursing appointment time, due to support at home by the communitymultiple problems being addressed team At the other end of thein one appointment. spectrum, the GP carried out the reviews of housebound patients.In terms of community andsecondary care involvement, one 7. EVALUATIONpractice mentioned good links with Although there was a paucity ofsecondary care and others formal evaluation, informal feedbackmentioned liaison with pharmacists from practices found that resultingfor medication review and district patient and staff satisfaction wasnurses and community matrons for high, mainly due to time saved duethe care of housebound patients. to multiple problems being addressed at one consultation. ThisHowever, some found that also led to more nursingcommunity staff did not have appointments becoming available.enough time to see all the patients Some practices also reportedidentified or were not trained to increased adherence to medicationmanage multiple problems. and reduced Accident and Emergency Attendances.Generally patients were referred tocommunity staff if needed but onepractice held fortnightly meetingswith the community matrons todiscuss housebound patients, as partof the requirement for the CCGLocally Enhanced Service (LES). 15
  16. 16. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?ChallengesSeveral practices highlighted trainingas one of the main challenges, sayinghigh quality training was vital forsuccess of the scheme to ensure staffwere skilled in assessing andmanaging multi-morbidity.Careful organisation and timemanagement were also essential,with enough time needing to begiven to appointments and allmeasurements such as bloods beingtaken beforehand.Practical resources were anotherchallenge. One practice needed tomodify their invite letter to optimisepatient attendance and found theylacked an appropriate template forentering all relevant data.Funding was the other mainchallenge that many practices cited.This was generally funding fortraining or extra clinical time, withevidence of evaluation and successfuloutcomes needed before furtherfunding could be provided.16
  17. 17. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?The way forwardThe move away from a disease- The NHS has organised chronic carecentric model of care towards a around a long term conditionspatient-centred multimorbid system model4, shown diagrammatically inraises several challenges for those figure 4 below. In recent yearsworking to deliver structured care. integrated care models have concentrated on patients at level 2The current Quality and Outcomes and level 3 who are high risk or withFramework is a major driver in ‘complex needs’. However, with thestructuring chronic care in general increased realization that patientspractice, but tends to be with multi morbidity are the normdisease-specific. As such, care needs rather than the exception, there isto be taken to ensure it does not also an increased need for integratedbecome a potential barrier to working at a practice level withdelivering effective integrated care in level 1 patients. Examples of this areconjunction with community teams. the involvement of CommunityFinancing of schemes may be more Pharmacists to minimizeappropriately made by using levers polypharmacy and attached practicesuch as Commissioning for Quality social workers to help deal withand Innovation (CQUIN)13 payments psychosocial problems.across a locality to encourage a moreintegrated approach to care. Figure 4: NHS Long-Term Conditions Model5There is a major need to developmultimorbid disease managementtemplates which are geared to theindividual patient and which take into LEVEL 3:account common psychosocial factors High complexity Casesuch as depression and the needs of managementcarers. Looking to the future there isalso a need to look at new ways ofdeveloping patient pathways and LEVEL 2: High riskguidelines away from the current Disease/case managementdisease specific models to moregeneric approaches around patientproblems e.g ‘disability orbreathlessness’. LEVEL 1: 70-80% of LTC population Self care support/management 17
  18. 18. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?ConclusionProactive chronic care of patientswith COPD and its co-morbiditiesprovides an exemplar for chronic careof patients with multimorbidity ingeneral practice. Examples of suchcare are limited but the final sectionof this document uses the keylearning points from this survey togive advice to general practicesplanning to offer structured chroniccare for people with multimorbidities.Learning from those sites whoresponded to the survey suggeststhere is a need for multimorbiddisease management templates andcare pathways, and that integratedworking with community teams,including pharmacists, can improveoutcomes, with the potential toreduce overall consultation times,increase patient satisfaction, reducepolypharmacy and reduce hospitaladmissions.18
  19. 19. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?Points to consider when organising structuredreviews for patients with COPD andco-morbidities in primary careKEY POINTS QUESTIONS TO CONSIDERBE CLEAR WHY YOU • What are the benefits to the practice and to the patients, carers or family? e.g less consultationARE REORGANISING time, fewer visits for the patient, achieving the objectives of a locally enhanced scheme.CARE • What are the likely financial consequences? • Consider canvassing CCG or local health group to provide finance/support for groups of practices under CQUIN/LES and to support work across boundaries.PRIOR PLANNING • Identify who is, could or should be involved in the organisation of care (e.g practice staff, community staff, pharmacist , social services, patients and carers) • Involve these stakeholders in the planning of care to increase understanding or what currently happens, what could happen and to encourage motivation for the service to succeed.IDENTIFICATION OF • Which co-morbidities will be included? Which are most common?PATIENTS • Are higher risk patients to be identified and how will this be done (e.g COPD patients with two or more exacerbations in the last year)?ORGANISATION • How will patients receive invitations and be reminded to attend appointments? • How will checks be organised? e.g number of appointments per patient, duration of appointments and which practice staff will be involved. • How much time is currently available and how is it used? How could it be used differently? Do you need any extra time? • What will happen in each appointment? • Do the staff have sufficient training in the co-morbid conditions to be reviewed? • How will the data be recorded? Are the disease templates sufficient for purpose? • Are practice management protocols sufficient for purpose? • Consider use of telehealth for higher risk patients. How could this enhance care?INTEGRATED CARE • How will care of patients be integrated with other members of the community team (and secondary care)? e.g pharmacist, social services, mental health services and specialist community teams. • How will the needs of patients deemed high risk and /or housebound be met by the community/practice team? • Will this satisfy the requirements of the QOF?EVALUATION How will you evaluate success? • Baseline and improvement - Where are you starting from? What do you need to measure as a baseline so that you can tell whether your changes are making a difference? What will you need to demonstrate to others to ensure support for the change? • Patient feedback – what do you want to know? How will you find out? What do patients think of the current service? What do they suggest might work better? How will you measure a change in their experience or satisfaction? • Consultation time – how much time is needed? How much time overall is needed, before and after? Who currently does what? • Costs and benefits – can you demonstrate reduced hospital admissions, reduced exacerbations, prescribing and adherence, QOF impact, use of urgent appointments or A&E, total cost of time and resources required, reduced duplication of tests or appointments? • Improved Quality of Life - using generic questionnaires such as Euroqol (EQ5-D)10 or disease specific questionnaires e.g COPD Assessment Test (CAT)11 • Increased patient enablement - using Patient Enablement Instrument.12Find resources such as First steps towards quality improvement: A simple guide to improvingservices to help you plan, deliver and evaluate your project at www.improvement.nhs.uk 19 7
  20. 20. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?References1. Barnett K, Mercer SV et al. Epidemiology of multimorbidity and implications for health care, research and medical education. The Lancet 360 9836: 38. 37-43.2. Fortin M, Soubhi H, Hudon C, Bayliss EA and MvD Akker. Multimorbidity’s many challenges. British Medical Journal 2007; 334 (7602): 1016-1017.3. Susan M Smith. Managing Patients with multimorbidity: systematic review of interventions in primary care and community settings. British Medical Journal 2012 292: 345 e52054. Kadam U. Redesigning the general practice consultation to improve care for patients with multimorbidity, British Medical Journal. 2012 Sep 17;345:e62025. National Clinical Guideline Centre. (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre. http://guidance.nice.org.uk/CG1016. Wagner EH, Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1) 2-47. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Pulmonary Disease(2011) www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html8. Diagnosis and Management of COPD in Primary Care. Primary Care Respiratory Society, UK www.pcrs-uk.org9. Shahid Ali . When a care plan comes together .Health Service Journal 9.12.2010 p2010. Euroqol(EQ-5D) questionnaire www.euroqol.org11. COPD Assessment Test. www.catestonline.org12. Howie, J. G., Heaney, D. J., Maxwell, M, & Walker, J. J. (1998). A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Family Practice, 15(2), 165-171.13. Commissioning for Quality and Innovation (CQUIN) payments. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_09144314. An Outcomes Strategy for COPD and asthma in England. 2011 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128428.pdf20
  21. 21. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?AcknowledgementsThanks to:The Project Committee of:Catherine Blackaby NHS ImprovementPhil Duncan NHS ImprovementRigoberto Pizarro-Duhart CIRC RCGPChristine Loveridge COPD/Spirometry Clinical Lead, Education for Health, WarwickDermot Ryan GP Principal LoughboroughMatt Kearney Department of Health Respiratory TeamSara Askew Primary Care Respiratory Society UK.The many practices who replied to the survey request, in particular Dr Joanne Reeve(Vauxhall Primary Health Care), Sharon Lamden (Leckhampton Surgery), Sarah Everett(Yellow Practice), Dr Dermot Ryan (Woodbrook Surgery), Liz Bryant and Deborah Dews(Birtley Medical Group), Professor Ruth Chambers (Furlong Medical Practice) and DrShahid Ali (Phoenix Medical Practice) for their contribution to the case studies.Chris Gush and Fiona Fordham from CIRC for administrative support.To Novartis Pharmaceuticals for providing financial support via anunrestricted educational grant. 21
  22. 22. Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?22
  23. 23. NHS NHS ImprovementCANCERDIAGNOSTICSHEART NHS Improvement NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improved patient experience and outcomes.LUNG Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements with over 250 sites across the country asSTROKE well as providing an improvement tool to over 2,400 GP practices. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow’s improvement agenda for the NHS Publication Ref: NHSIMP/Lung0006 - March 2013 ©NHS Improvement 2013 | All Rights Reserved

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