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CommissioningCare Pathways for Chronic Diseases                           James Gupta     Medical Student | University of ...
Overview & Aims   What are pathways, when do we use them    and why do we need them?   Developing a pathway-based approa...
What is a „Pathway‟?                       © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
Post-op complications fell 33%Inpatient deaths by 40%                                 © James Gupta 2012 | james.gupta@hst...
What is a „Pathway‟?“Integrated Care Pathways (ICPs) provide a template for multi-disciplinarycare that is evidence-based ...
What is a „Pathway‟?“A template for multidisciplinary care that isevidence-based and coordinated.”                     Mu...
What is a „Pathway‟?“A template for multi-disciplinary care that isevidence-based and coordinated.”                    Mu...
What is a „Pathway‟?“A template for multi-disciplinary care that isevidence-based and coordinated.”                      ...
What is a „Pathway‟?“A template for multi-disciplinary care that isevidence-based and coordinated.”                   Mul...
Available from sthealth.org.uk/copd_resources.htm
Why do we need pathways?   Time & budget restraints   Patients receiving care from different    professionals   Need to...
When do we use pathways?   We all use pathways, every day   Structured decision-making    process based on knowledge    ...
What are the benefits of using                                                         pathways?                          ...
Developing a Pathway Approach toCOPD Commissioning   Multidisciplinary     Chest physicians                     • Assemb...
Developing a Pathway Approach toCOPD Commissioning   Assess your current patient    journey:                             ...
Primary/Secondary Care Conflict Peter – Consultant chest                            Wendy – Practice nurse physician      ...
Primary/Secondary Care Conflict                                                              “We‟re really busy in“Patient...
Developing a Pathway Approach toCOPD Commissioning   The hardest part                                           • Assembl...
Measuring the impact of pathways onpatient care   QOF                                                          Admissions...
Commissioning Quality Markers:Measuring the impact of pathways onpatient care   Must ultimately focus on REAL     Bed Day...
Commissioning Quality Markers   Should focus on real outcomes    where possible       Admissions / Exacerbations       ...
Commissioning for Whole-PersonCare   COPD is being increasingly seen as a systemic disease with    associated co-morbidit...
Case Study: StHealth COPDProject   Joint working initiative with GlaxoSmithKline    (DH toolkit)   StHealth Practice Bas...
Key Pillars                        Stakeholder                        Engagement           Outcome        Pathway         ...
3. Developed and                        2. Patient pathway                 implemented a1. JW business case        and tre...
QIPP       © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
Summary   Pathways are multidisciplinary, evidence-based, local & specific   Take best available evidence and adapt it t...
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Commissioning Care Pathways for Chronic Diseases

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Commissioning Care Pathways for Chronic Diseases / Long Term Conditions

This was a presentation I made recently for a conference on Long Term Conditions which was unfortunately cancelled, but I had already written and researched the slides so wanted to put them up for people to see!

Explains how to commission effective services to deal with patients suffering from long-term (chronic) conditions

Published in: Health & Medicine
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Commissioning Care Pathways for Chronic Diseases

  1. 1. CommissioningCare Pathways for Chronic Diseases James Gupta Medical Student | University of Leeds QIPP Lead | Windermere Medical Centre James.Gupta@hsthpct.nhs.uk
  2. 2. Overview & Aims What are pathways, when do we use them and why do we need them? Developing a pathway-based approach to COPD commissioning How can we measure the impact of pathways on patient care? Commissioning for „whole person‟ care Our experience (overview of the StHealth COPD project) © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  3. 3. What is a „Pathway‟? © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  4. 4. Post-op complications fell 33%Inpatient deaths by 40% © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  5. 5. What is a „Pathway‟?“Integrated Care Pathways (ICPs) provide a template for multi-disciplinarycare that is evidence-based and co-ordinated.” – Clinical Governance, NHS Scotland 1“An integrated care pathway (ICP) is a multidisciplinary outline of anticipatedcare, placed in an appropriate timeframe, to help a patient with a specificcondition or set of symptoms move progressively through a clinical experienceto positive outcomes.”– Oxford University Medicine 2“A care pathway is anticipated care placed in an appropriate time frame,written and agreed by a multidisciplinary team. It has locally agreed standardsbased on evidence where available to help a patient with a specific conditionor diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency 3 1) NHS Scotland Clinical Governance, What are integrated care pathways, http://www.clinicalgovernance.scot.nhs.uk/section2/pathways.asp 2) Bandolier, Integrated care pathway, http://www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html 3) Welsh Assembly Government, Innovations in care 2003. © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  6. 6. What is a „Pathway‟?“A template for multidisciplinary care that isevidence-based and coordinated.” Multidisciplinary – Clinical Governance, NHS Scotland“A multidisciplinary outline of anticipatedcare, placed in an appropriate timeframe, tohelp a patient with a specific condition or set ofsymptoms move progressively through aclinical experience to positive outcomes.”– Oxford University Medicine“Anticipated care placed in an appropriate timeframe, written and agreed by amultidisciplinary team. It has locally agreedstandards based on evidence where availableto help a patient with a specific condition ordiagnosis move progressively through theclinical experience.”- Welsh National Leadership and InnovationAgency © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  7. 7. What is a „Pathway‟?“A template for multi-disciplinary care that isevidence-based and coordinated.”  Multidisciplinary – Clinical Governance, NHS Scotland Evidence-based“A multidisciplinaryoutline of anticipated care,placed in an appropriate timeframe, to help apatient with a specific condition or set ofsymptoms move progressively through aclinical experience to positive outcomes.”– Oxford University Medicine“Anticipated care placed in an appropriate timeframe, written and agreed by amultidisciplinary team. It has locally agreedstandards based on evidence where availableto help a patient with a specific condition ordiagnosis move progressively through theclinical experience.”- Welsh National Leadership and InnovationAgency © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  8. 8. What is a „Pathway‟?“A template for multi-disciplinary care that isevidence-based and coordinated.”  Multidisciplinary – Clinical Governance, NHS Scotland  Evidence-based“A multidisciplinaryoutline of anticipated Anticipatedcare, placed in an appropriate timeframe, tohelp a patient with a specific condition or set ofsymptoms move progressively through aclinical experience to positive outcomes.”– Oxford University Medicine“Anticipated care placed in an appropriatetime frame, written and agreed by amultidisciplinary team. It has locally agreedstandards based on evidence where availableto help a patient with a specific condition ordiagnosis move progressively through theclinical experience.”- Welsh National Leadership and InnovationAgency © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  9. 9. What is a „Pathway‟?“A template for multi-disciplinary care that isevidence-based and coordinated.”  Multidisciplinary – Clinical Governance, NHS Scotland  Evidence-based“A multidisciplinaryoutline of anticipated Anticipatedcare, placed in an appropriate timeframe, tohelp a patient with a specific condition or setof symptoms move progressively through a Local & Specificclinical experience to positive outcomes.”– Oxford University Medicine“Anticipated care placed in an appropriatetime frame, written and agreed by amultidisciplinary team. It has locally agreedstandards based on evidence where availableto help a patient with a specific condition ordiagnosis move progressively through theclinical experience.”- Welsh National Leadership and InnovationAgency © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  10. 10. Available from sthealth.org.uk/copd_resources.htm
  11. 11. Why do we need pathways? Time & budget restraints Patients receiving care from different professionals Need to make care as efficient as possible and reduce variation Every patient is unique, but key features will be seen repeatedly © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  12. 12. When do we use pathways? We all use pathways, every day Structured decision-making process based on knowledge (evidence) and experience © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  13. 13. What are the benefits of using pathways?  Patients receive care that is not only more consistent, but also of a higher standard and more up to date with the latest evidence  Clinicians feel more confident and can get more done in less time  Resources are used more appropriately  Emergency / non-elective admissions can be reduced  Rotter et al Cochrane Review 20101) Rotter et al, Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006632. DOI: 10.1002/14651858.CD006632.pub2. 2) Campbell H, Hotchkiss R, Bradshaw N, Porteous M, Integrated care pathways. BMJ 1998, 316(7125):133-7. 3) Lowe C, Care pathways: have they a place in „the new National Health Service‟? J NursManag 1998, 6(5):303-6. © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  14. 14. Developing a Pathway Approach toCOPD Commissioning Multidisciplinary  Chest physicians • Assemble a  GPs 1 team  Practice nurses  COPD / community nurses  Practice managers • Design a  Pharmacists  Respiratory physiotherapists 2 pathway  Smoking cessation advisers  Spirometry technicians Committed • Implement it Lead: clinical and managerial 3 experience © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  15. 15. Developing a Pathway Approach toCOPD Commissioning Assess your current patient journey: • Assemble a  Time wasters 1 team  Black holes  Bottlenecks Plan a new patient journey • Design a  THINK OUTSIDE THE BOX! 2 pathway Listen to the views of ALL your MDT equally regardless of „seniority‟ or qualifications. Expect some „culture shock‟ between • Implement it primary and secondary care 3 professionals, encourage it! © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  16. 16. Primary/Secondary Care Conflict Peter – Consultant chest Wendy – Practice nurse physician © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  17. 17. Primary/Secondary Care Conflict “We‟re really busy in“Patients should have full primary care so don‟tpost-bronchodilator always have time to dospirometry performed by spirometry – often we canan accredited technician see how a patient isevery time they come for getting on by asking thema review – other questions, their generalmeasures of lung function appearance, peak flowsimply aren‟t accurate etc”enough”Peter –chest physician Liz – Pathway lead Wendy – Practice nurse © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  18. 18. Developing a Pathway Approach toCOPD Commissioning The hardest part • Assemble a Simply distributing the final team pathway will not work 1 Has to be done alongside structured clinician education • Design a Advertise the mutual benefit: 2 pathway  Improve patient care AND  Make your job easier! Resistance to change • Implement it 3 © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  19. 19. Measuring the impact of pathways onpatient care QOF Admissions / NICE Exacerbations  Flu jab L12M Bed Days  FEV1 L15M  MRC score L15M Inhaler PHQ Respiratory Technique Prescribing Not acceptable!! Many ways to measure Pulmonary Rehabilitation Referrals Quit Rates REAL changes in the patient experience Clinician Patient FEV1 at Identify them early! Confidence Satisfaction Diagnosis © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  20. 20. Commissioning Quality Markers:Measuring the impact of pathways onpatient care Must ultimately focus on REAL Bed Days / Admissions clinical outcomes Mortality Primary QOL Endpoints May take many years to see full Cost Reduction benefit of these FEV1 Decline Surrogate Surrogate endpoints in Medication Adherence Endpoints Smoking Quit Rates meantime NICE Compliance Cost reductions / QIPP Data recording Process Early detection Markers © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  21. 21. Commissioning Quality Markers Should focus on real outcomes where possible  Admissions / Exacerbations  Quality of life (King George, PHQ9)  Smoking quit rates  Costs  Referrals  Prescribing  % referred for pulmonary rehab © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  22. 22. Commissioning for Whole-PersonCare COPD is being increasingly seen as a systemic disease with associated co-morbidities:  Depression  Heart Failure  Osteoporosis (corticosteroid-induced)  Hypertension  Cardiovascular disease  Lung cancer  Bronchiectasis Yet current care-pathways do not operate like this – definitely something to bear in mind Good model: diabetes – common co-morbidities / complications are treated and screened for under one (relatively) cohesive model 1) Barnes PJ, Celli Br, Systemic manifestations and comorbidities of COPD. EurRespir J 2009, 33(5);1165-85 © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  23. 23. Case Study: StHealth COPDProject Joint working initiative with GlaxoSmithKline (DH toolkit) StHealth Practice Based Commissioning Consortium (now Shadow CCG) Focused on enhanced management AND early detection of COPD Pathway-based Led to  reduction in hospital admissions and prescribing costs,  increase in patient satisfaction, quality of reviews, © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  24. 24. Key Pillars Stakeholder Engagement Outcome Pathway Screening Measurement Development Clinician Training © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  25. 25. 3. Developed and 2. Patient pathway implemented a1. JW business case and treatment training and committing £290k protocol developed mentoring programme 5. Investing in 4. Implemented 6. Measure patient Vitalograph COPD6 POINTS auditexperience of service FEV1 monitors software © James Gupta 2012 | UK/MARK/0023/10 – April 2010 james.gupta@hsthpct.nhs.uk
  26. 26. QIPP © James Gupta 2012 | james.gupta@hsthpct.nhs.uk
  27. 27. Summary Pathways are multidisciplinary, evidence-based, local & specific Take best available evidence and adapt it to local needs & provision Can increase standard of care for chronic conditions Reduce costs, admissions/bed days and improve quality of life Need to identify commissioning quality markers © James Gupta 2012 | james.gupta@hsthpct.nhs.uk

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