Angus Demographics• Total population 109,320• Lower than Scottish average population of working age• Higher life expectancy in both men and women• 0.8% ethnic minority population• All cause mortality and heart disease mortality lower that Scottish average and cancer mortality amongst lowest in Scotland.
Demographics (continued) • Proportion of population hospitalised for alcohol or drug related causes amongst lowest in Scotland • Significantly lower rate of acute admissions • Lower levels of homelessness • Lower levels of deprivation (Source: Scot PHO Health & Wellbeing Profile, 2008)
The Angus Journey in Complex Care Management: Step One•Preliminary studieswithin generalpractices in 2006,reviewing complexcare pts on basis ofUniquecare criteria
Key Findings from PreliminaryStudies • Patients identified through this process all deemed as complex by professionals involved • Patients were not high users of unscheduled care • All patients proactively managed within general practice, with impact of QoF evident
• Recurring themes in those who did have > unscheduled care ( COPD, mental health and/or alcohol issues)• Issues in entire adult population, not particular to older age groups• Key issues related to coordination of services between primary and secondary care
Uniquecare Criteria vs SPARRA • Scottish Patients at Risk of Readmission and Admission identified fewer pts than Uniquecare approach (focussed on >65’s) • 40% pts on SPARRA list had been identified by initial approach • 27% pts on SPARRA but not in initial approach had died • Of remaining 33% pts on SPARRA but not in initial approach, renal issues was a predominant feature. Implications of QoF coding also noted
Uniquecare vs LA CareManagement • Small numbers receiving complex care packages within LA • 17% pts with complex care packages <65 yrs, 73% >65 years. • Many had just one long term condition, with an impact on ability to self manage • Stroke a predominant feature
Heart Disease Mental Health Circulatory Ill Defined Digestive Cancer Injuries COPD Other Resp Townhead Practice Patients with 70-90% Risk of Admission Springfield MC - West Springfield MC - East Ravenswood Surgery Monifieth HC Lour Rd Gp Practice Kirriemuir HC Friockheim HC Edzell HC Castlegait Surgery ParkviewThe Angus Journey: Step 2 Brechin HC Arbroath MC Annat Bank Practice Academy MC Abbey HC 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Patient Numbers Early SPARRA Total Number of Patients at Risk of Admission Townhead Practice Springfield MC - West Springfield MC - East Ravenswood Surgery Monifieth HC Lour Rd Gp Practice Kirriemuir HC Friockheim HC Edzell HC Castlegait Surgery Parkview Brechin HC Arbroath MC Annat Bank Practice Academy MC Abbey HC 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Pop As a % of Practice
The Angus Journey: Step 3 Gold Standards Framework for LTC’s in General Practice•The Gold Standards Framework (GSF) is a‘systematic evidence based approach tooptimising the care for patients nearing the endof life in the community’.•The focus of GSF is to improve care in thecommunity by optimising the local primary careteam’s provision, so that more patients areenabled to live and die where they choose, andun-needed hospital admissions are avoided.
3 processes of GSF include:• Identification of patients in need of palliative/supportive care• Assessment of needs, symptoms, preferences etc• Care planning and delivery.
5 GSF Goals:• Good symptom control.• Patients enabled to live and die well in their place of choice.• Better advanced care, planning, information, less fear, fewer crisis/hospital admissions.• Well supported and informed carers.• Staff confidence, communication and co- working.
Aims of GSF Project for LTC’s•To explore the impactintroduction of the GoldStandards Framework (GSF)in the management ofcomplex Long TermConditions Management,within primary care, had onpatient outcomes and staffsatisfaction
Pilot Details• Based in Academy Medical Centre, Forfar• Large teaching practice• Practice population 10990• 81% being under the age of 65• 19% over the age of 65.• Multi-agency participation• 2008-9
‘Top Ten’: Identification• Identified through SPARRA and Tayside Predictive ToolOr• Recommendation of patients by core team member and approval by others• Any adult eligible for inclusion and the project did not focus exclusively on any given areas of priority from a disease, multi- disease or age perspective
Project Plan• Education of staff re aims of complex care management, & GSF• Core list of ‘top ten’ agreed by core team• Inclusion in supportive care register• Monthly meets aimed to improve the flow of information, advance care planning and measurement/audit of outcomes• Shared care planning
Our Top Ten!Pati Age Long Term How Services at New Emergency Emergencyent Conditions Identified? Outset of services or Care CareNo (List all) Sparra/PEONY Project changes to Contacts Contacts / eg GP, DN care as a 6/12 pre-pilot 6/12 during Team/Other result of pilot pilotEg 85 CHD District Nurse DN Care 10 5 Diabetes Not on GP management SPARRA1 69 DIABETIC PN PN 3 0 HYPERTENSI ON2 61 CHD CM CM+DN 0 0 and no MS GP visits3 79 COPD SPARRA PRACTICE 2 2 CKD4 68 COPD DN ALL DIED DIED DIED CKD5 74 DIABETIC DN DN + CM 2 2 HYPERTENSI ON COPD6 83 HYPERTENSI DN DN 0 0 and 0 ON OOH CHD callouts COPD CKD
Patie Ag Long Term How Identified? Services at New services Emergency Emergencynt e Conditions Sparra/PEONY/ Outset of or changes to Care Contacts CareNo (List all) Team/Other Project care as a result 6/12 pre-pilot Contacts eg GP, DN of pilot 6/12 during pilot7 59 DIABETIC DN DN PN 0 0 and 0 OOH CHD callouts CKD8 82 HYPERTENSION CM CM + DN 1 0 and 0 OOH CHD callouts9 67 HYPERTENSION CM CM 3 0 MS10 78 CHD SPARRA CM + 2 0 and 0 OOH PRACTICE callouts TOTALS 13 4
Q1. In your opinion, has this project improvedcommunication between the professionals involved in the care of the patients included? 0% Yes No DNA Q2. Has your understanding of the roles 100% performed by other professionals involved in the project improved as a result of this project? 14% Yes 14% No DNA 72% Q11. Do you feel that this project has been a success? 0% Yes No DNA 100%
Staff Views on Most Effective Means of Pt Identification• ‘Case discussion. SPARRA chose patients that were deceased or had very little input from both social work and health’• ‘I decided to use the SPARRA data as a tool for identifying my patient. This proved ineffective due to its basis on retrospective data and in fact my patient had no admissions or GP contacts during the duration of the pilot despite multiple co-morbidities and numerous preceding issues, which required MDT work.’• ‘SPARRA search and individual proposal of suitable patients. Some patients we felt who would be suitable for inclusion did not appear on the electronic search’• ‘Individual/team knowledge’• ‘Best “mechanism” for patient identification was without doubt the DNs!’
The Angus Journey: Step 4• Cross reference of SPARRA lists with existing care/case management services, to aid dissemination of information/use of data• General Practice : Quality & Outcomes Framework +• COPD Anticipatory Care Project
COPD Anticipatory Care ProjectAll COPD patients All COPD patients Clinical agreementregistered with registered with Montrose of suitability of anyMontrose practice practice with COPD other COPDwith COPD related identified by SPARRA as patient registeredadmission duringperiod of pilot being at risk of recurrent with Montrose admission practice Agreement of inclusion of patient in anticipatory care project by clinicians with links with Palliative Care DES and advice from other agencies where appropriate. (Maximum caseload to be agreed, approx 15 patients at any given time) 1. Holistic assessment by COPD nurses offered to all patients identified through SPARRA or team, who have not had a COPD assessment by housebound service within last 6 months. 2. In addition to normal care, all COPD related discharges will receive a joint assessment visit by DN and COPD housebound nurse on the next working day after discharge (even where ESD in place). 1Care plans to be developed, with a focus on patient goal setting and self management education, using the BLF COPD Self-Management Plan in all cases, and Palliative Care DES information if appropriate. 2 Anticipatory care planning for all patients, including recording of information in OOH systems. 3 Urgent referral to pulmonary rehabilitation if appropriate. 4 Standardised community and COPD housebound nursing documentation to be used. 5 Ongoing implementation of care plan, with minimum of 3/12 review.
Criteria Pt1* Pt2 Pt3* Pt4* Pt5*Smoking status Smoker Smoker SmokerImmunisation status Assessment of MRC 3 3 2 2 3dyspnoea scoreMedication review Inhaler technique Education Self-management BLF booklet BLF booklet BLF booklet BLF booklet BLF bookletCo-morbidities Assessment of psychological co-morbidityAnticipatory care planning on Taycare on Taycare on Taycare on Taycare on TaycareOthers Taxicard Referral for anxiety mgt OT referral Meds changes Smoking cessation Rescue meds New devices Exercises Devices changes advice Exercise advice Referral to pulmonary Rescue meds New devices rehab CMT referral Meds changes Exercise on referral Referral to pulmonary rehabStatus at end of On DN service books Admitted onto DN Admitted onto DN Discharged Discharged back to PNproject prior to project. Care caseload & COPD caseload & COPD ongoing Housebound service Housebound service
Pt6* Pt7 Pt8* Pt9Smoking status SmokerImmunisation Status Assessment of MRC 4/5 3 5 4Dyspnoea ScoreMedication Review Inhaler Technique Education Self Management BLF booklet BLF booklet BLF booklet BLF bookletCo-morbidities Assessment of Psychological Co-morbidityAnticipatory Care Planning on Taycare on Taycare on Taycare on TaycareOthers Rescue meds Rescue meds Meds changed Flu vac Continence assessment Flu vac Rescue meds Referral to pulmonary Oral thrush identified and tx, Inhaler technique rehabilitation and oral hygiene taught Dental referral Rescue meds Commenced antidepressants Referral to pulmonary rehab Reliant of nebulisers Taught re use of aerochamber Portable O2 arranged for holidaysStatus at End of Project On DN service books prior to Discharged back to PN On DN service books prior to Admitted onto DN caseload project. Care ongoing project. Care ongoing & COPD Housebound service
General Observations RegardingSPARRA •Accuracy of data sources •1/4rly report limiting •? Finding patients too late? •? Disadvantaged by lack of GP data feed? •Variable use of SPARRA data To effectively implement and evaluate systems for complex care, we need a tool to effectively identify those who we can effectively make a quantitative as well as qualitative impact