Complex Care Management In Practice

Dunblane

Tuesday 6th November 2007

Pre 2003

Paper case notes Green recall sheet in case notes GP recalled patients using computer generated

non specific recall systemHowever

Case notes not available for consultation Green sheets not updated Patients not sure why attending Patients recalled by disease

Patients Recall

Multiple visits for patients with more than 1 condition

Duplication of tests Patients time –travelling work etc Patients expenses Medical Care appeared disease centred

not patient centred

Post 2003

Surgery started to become paper light Dr Dunlop had been developing a

computer recall programme –Dunlop Recall Management (DRM)

Trial of DRM on male patients with hypothyroidism

Co-prevalenceco-prevalence of disease in Male patients with

hypothyroidism

0

2

4

6

8

10

12

1 2 3 4 5

number of major disease classifications(incl hypothyroid)

nu

mb

er

of

pa

tie

nts

Comorbidity(the simultaneous presence of multiple chronic conditions)

Co-morbidity in male patients with hypothyroidism (n=28)

0

2

4

6

8

10

12

14

16

none BP CHD COPD Asthma Cancer Stroke Diabetes Epilepsy MentalIllness

other

major disease category incidence

num

ber

of p

atie

nts

During 2004

All patients with a Chronic Disease added to DRM

All patients requiring follow up added to DRM i.e.Injections Baby 6 week checkRoutine blood testsIUCD checks

Protocol developed for newly registered patients to be added to DRM

Complex Care Nurse Specialist Role

Managing co-mobidityProactive Recall and Team ManagementDelivering Patient Centred Scheduled Care efficiently by the Primary Care Team

Managing co-morbidity

Co-morbidity varies with each diagnosis use of resources depends on the degree

of co-morbidity (co-prevalance) rather than the diagnosis

30% patients on recall management (5034 patients)

Riverview Medical Centre 3 GP’s 2 GP Registrar’s 1 FY2 1 Practice Nurse 1 Health Care Assistant 1 Phlebotomist 2 District Nurses 2 Health Visitors

Medical Staff

Practice Employed

Health Board Employed

Clinical Care Follow Up Plan Maps the patient journey: GP/ community /

hospital Explains the patient journey: items of care Team members responsible for care Hands over responsibility to the patient Safety nets the deal with a further plan sent by

post should the patient default (plan may be altered with revised information)

Date of issue & any freetext Read coded in primary care system

CCFUP scanned into Docman before sending

Clinical Care Follow Up Plan- upper page

Clinical Care Follow Up Plan- lower page

Complex Care Nurse Specialist Tasks

Creates new electronic patient management plans Trains staff how to use recall system checks missed deadlines report daily (results not back;

recalls: DN) & advises health care assistant or admin staff which recalls can be sent by them; checks care plan details & appts of others – reassessing clinical need.

Delivers chronic disease management at the higher skill level +/- prescribing, maximising own skills

Defining and controlling practice resources

Missed Deadlines Report

The Team

DRM updated by Dr’s PN and HCA during consultations

Clinical Care Plans generated and given to DN’s, Phlebotomist and HV’s as appropriate

Important to know the nursing team and their level of skills and competences

Good rapport and communication skills

Plan Implementation - Community

Clinical care plan returned to PN after consultation Information entered onto computer Clinical decisions made depending on results Medication alterations- contact patient or liaise with

pharmacy for change of medication or alteration in dosages. Refer to other Health care services if required Arrange other tests/ investigations Planned review date and DRM updated GP intervention if required

WORKING TOGETHERComplex Care Nurse Specialist Role in scheduled primary care

PatientScheduled Care : Unscheduled Care

?nurse advice

Receptionist appt <48hr NHS 24 Nurse Advice

checks patient mgt plan

?dr advice routine ?links Hospital Admission

Appointment System

Routine Housebound Same day/48hr

GP Tel Consultation/Triage Advice +/- script ; appt

patient tel

SCI Gateway

data added risk mgt (add follow up codes

where required) tel direct access

Posted to Patient GP specialist and/or

Clinical Care Follow Up Plan

Recall

Electronic Patient Management Plan -contract data -red flag symptoms -other clinical follow up (eg IUCD,B12); referral pathways

Electronic Patient Record

AUDIT

Fast track Intermediate care

(Clinic or Nurse Specialist) eg

EPU;Physio (low back pain) ; other

consultant opinion

risk mgt

Complex Care Nurse Specialist reports and letters

Missed Deadlines Report

Benefits For Patient Patient centered not disease centered care Minimising visits to surgery Reducing financial outlay work and travelling Prevents duplication of tests and proceedures Improved relationships patients/ Gp’s and staff

For PN / Surgery Less time spent on recall Improved working relationships -teamwork learning needs Identified Greater job satisfaction

Constraints

Time IT programme needs further development Barrier to referrals for Nursing staff-

although slowly resolving.

Finally:-

If you have been……

Thanks for Listening