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Dr Junaid Bajwa, General Practitioner, NHS Greenwich CCG

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Transforming LTC Management in Primary Care – what practical steps can be taken to improve patient care?

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Dr Junaid Bajwa, General Practitioner, NHS Greenwich CCG

  1. 1. Long Term Conditions Risk Optimisation Dr Junaid Bajwa Conway Medical Centre, Greenwich
  2. 2. About me • GP, CCG Governing Body Member NHS Greenwich (s) • Associate in Public Health, NHS Greenwich (s) • Council Member of the Clinical Senate, London • NHS Fast Track Executive Programme • GP Appraiser NHSE • Programme Director, Greenwich VTS (s) • Prepare to Lead alumni, NHS London • Value Based Healthcare Alumni, Harvard Business School
  3. 3. The IHI healthcare Triple Aim
  4. 4. Multimorbidity: LTC – The majority of >65s have 2+conditions, & the majority of >75s have 3+ conditions – More people have 2 or more conditions than only have 1
  5. 5. The working lunch….. Monday Tues Weds Thurs Fri 0800am 0810am 0820am 0830am 0840am 0850am 0900am 0910am 0920am 0930am 0940am 0950am 1000am 1010am 1020am 1030am 1040am 1050am 1100am 1110am 1120am 1130am 1140am 1150am 1200pm 1210pm 1220pm 1230pm 1600pm 1610pm 1620pm 1630pm 1640pm 1650pm 1700pm 1710pm 1720pm 1730pm 1740pm 1750pm 1800pm 1810pm 1820pm 1830pm 1840pm 1850pm 1900pm • 16 face to face 10 minute appts • Telephone encounters: 5-10 • Home visits (2-3) • Referrals: 3 (am) • Review blood tests/Investigations • Post/ Fax/ Email (75-100 letters per day) • 16 face to face 10 minute appts • Referrals: 3 (pm) What about: QoF/ LES/DES/ CIS/ Additional Services/ Child Protection/ GSF/ Information Governance/ CQC/ PRG/ Practice Meetings/ KPI’s/ Audit: Research/ Reviewing Prescribing/ HR issues/ LMC/ Public Health/ CCG ….(+++++++++++)…. Stepping outside the chaos to manage LTC holistically Proactive, not reactive medicine
  6. 6. GP’s and Nurses in deprived areas struggle with LTC’s “Exhausting” “Demoralising” “I feel like a wrung-out rag at the end of consultations” “If you’re too caring ... you’ll crack up in a place like this. Our boundaries lie where they are because they have to at the moment” Proactive management, not reactive
  7. 7. Long Term Conditions Module Improving the experience of healthcare for those with long term conditions
  8. 8. What if we used what we have? Metrics • HbA1c • Cholesterol • BP • MRC • eGFR* • BMI • Waist circ • Audit C score • PHQ9 • Being Housebound • No of repeat • Age >75 • Being a smoker Long Term Conditions • Cancer, • COPD, • Asthma, • Diabetes, • CKD 3,4,5, • Hypertension, • Rh Arthritis, • AF, • HF, • Hypertension, • Mental Health condition, • LD, • Dementia, • Parkinsons, • Cirrhosis, • being on the GSF, • Inflammatory Bowel Disease, • Stroke/TIA, • Osteoporosis
  9. 9. What if we used what we have? Metrics • HbA1c • Cholesterol • BP • MRC • eGFR* • BMI • Waist circ • Audit C score • PHQ9 • Being Housebound • No of repeat • Being a smoker Long Term Conditions • Cancer, • COPD, • Asthma, • Diabetes, • CKD 3,4,5, • Hypertension, • Rh Arthritis, • AF, • HF, • Hypertension, • Mental Health condition, • LD, • Dementia, • Parkinsons, • Cirrhosis, • being on the GSF, • Inflammatory Bowel Disease, • Stroke/TIA, • Osteoporosis • Age >75 (Modifiable) (Fixed)
  10. 10. Within the metric….RAG Metrics • HbA1c • Cholesterol • BP • MRC • eGFR* • BMI • Waist circ • Audit C score • PHQ9 • Being Housebound • No of repeat • Age >75 • Being a smoker RAG: R-2pts / A-1pt / G-0pt • G (6.5-7.5), A (7.5-8.5); R (>8.5) • > 4:2: A: 1 pt if above this ratio • (>150/90; if DM/CKD/CHD >140/90) 1 pt if above • G: 3,A: 4, R: 5 • G (CKD2 60-89); A (CKD3 30-59); R (CKD4,5 ie < 29) • A: (Obese**) R (:morbid obesity) • A: 1 pt if above norm • R: (>5) • (last recorded within 3m) R: 15-27; A: 5-14 • A: 1 point • Repeat medications (>5): A 1 pt if above • A 1 pt if above 75 • A 1pts
  11. 11. Managing the chaos: Proactive vs Reactive • Cumulative totals within each of the categories would then allow a 360° review of your registered population • Could you then establish a set of rules re: appointments; removing the monthly letters for each review/ reduce waste in the system; offer extended appointments with a focus on self management- improving the patient experience Green Amber Red Dr appts (?around bday) 2/yr 3/yr 4/yr Nurse appts 3/yr 4/yr 5/yr
  12. 12. PDSA: future add ons • PDSA cycle • Coding: Number of hospital admissions A(2); R(>3); • Quantify length of stay in hospital • QRISK®2 calculates your risk of cardiovascular disease(R >30%) (A>20) • QDScore® algorithm calculates your risk of Type 2 diabetes.) • QoL score (would be useful to include this metric- we do not currently assess this in primary care) • Looking at social determinants of health: e.g. personal/ household income, social housing, postcode, use of carers, social isolation “Not all that can be counted, counts. And not all that counts can be counted.” -- Albert Einstein
  13. 13. Personal Health Plan
  14. 14. Personal Health Plan
  15. 15. Personal Health Plan
  16. 16. Improving the Patient Experience
  17. 17. Find out More at the MSD Healthcare Services stand Thank you…

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