dr john d dean, md frcp

Designing and Delivering care for people with Long Term Conditions

What can the NHS learn from other countries? What can the NHS teach other countries?

Dr John D Dean, MD FRCPMedical Director for Quality and Care Improvement,

Consultant Diabetologist, Bolton Primary Care Trust.

Health Foundation Fellow, Institute for Healthcare Improvement

Objectives

Share my experience • Early learning

– Developing integrated diabetes service

• A broader perspective– Year’s sabbatical at IHI\USA studying improving

chronic care

• Bringing the lessons home– Translating learning into designing and delivering care

for a local population in NW England

• Learning for others from NHS

Diabetes Care in Bolton

• 12,300 people registered with diabetes = 4.6 (1.9-6.3) %• 9.3% south asian population - Gugerati

• 57 General Practices, – 90% of practices structured diabetes care– 80% patients primary care only

• Community based diabetes specialist team– Bolton Diabetes Centre - 1995– 20% of patients, mainly complex or at transition

Ethos of Specialist Team

To facilitate and provide high quality patient centred diabetes care throughout Bolton,

through education and expert practice

Bolton Diabetes CareKey time points1989 Regional Review of Diabetes Care1992 Multi-agency planning group established (LDSAG)

Plans for “town centre” Diabetes Centre for specialist carePrimary Care Education days commenced

1994 Consultant Physician and lead Nurse appointedCare agreements established with each general practice

1995 Bolton Diabetes Centre opened – Town Centre1995 -2002 Specialist Clinics developed

2nd Physician appointedExtension of primary care professional education Expansion of nursing team through “opportunities”, ‘

Nurse Consultant2001 External Diabetes Services review2002/3 NSF Diabetes2004 Specialist Service transfers to of PCT 2006 Our Health, Our Care, Our say

‘Bolton’s Diabetes Journey’

External Review - 2000/1

STRENGTHS STRENGTHS

• Strong leadership from Diabetes Centre

• The Diabetes Centre team is able to offer multidisciplinary consultations for patients with complex needs

• Many examples of good and innovative practice in specialist, primary and community care

• Practice nurses-extensive training and experience in diabetes (10 yrs)

• Podiatry screening service consistently praised

• Good teamwork in the management of diabetic foot ulcers

RECOMMENDATIONSRECOMMENDATIONS

• Reduce variation in primary care

• More practice based education is needed

• More specialist interaction with primary care

0 20 40 60 80%

4%

9%

13%

70%

4%

1 Balance between specialist and primary care appropriate

2 More emphasis on specialist care, less on primary care

3 More emphasis on primary care, less on specialist care

4 Balance appropriate but needs to be more integrated

5 Need for intermediate levels of care

Bolton Diabetes Care Strategy

Diabetes Care in Bolton

THE VISION:“INTEGRATED DIABETES CARE”

Patient centred not organisation centred

Care should be deliveredat the appropriate time, in the appropriate place,

by the appropriately trained professional, for that patients present needs

Objectives of Integrated Diabetes Care in Bolton

• fully integrated service

• avoid any gaps or duplication in service

• smooth and quick referral from primary care for advice and management plan

• increased specialist input into primary care settings

• consistent high quality patient centred care

Define level of provision by Practice

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Practice 1

Practice 2

Practice 3

Practice 4

Practice 5

Complemented by the Diabetes Specialist Service

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Practice 1

Practice 2

Practice 3

Practice 4

Practice 5

2003

Level 1

Level 2

Level 3

Level 4

Level 5

Primary Care Specialist Care

Strategy

Level 1

Level 2

Level 3

Level 4

Level 5


Specialists working in Referral for advicePrimary Care and management plan

Level 3

Level 4

Level 5


Specialists working in Referral for advicePrimary Care and management plan

2007

Shared vision Clear accountable leadership Defined and agreed roles and responsibilities of staff and

organisations Common Patient Record and Information

Integrated Management Integrated Management

- the local - the local managed managed diabetes networkdiabetes network

Specialist team part of PCT by April 2004 Specialist team part of PCT by April 2004

Pre requisites for integrating care

What does this mean for Staff?

PRIMARY CARE STAFF• Clear remit and managerial

support to deliver level of care

• More access, support and education from specialists, to agreed level

• In practice time for education

• More care delivered in primary care

SPECIALIST STAFF• Clear remit and managerial support • Time spent in primary care• Devolving appropriate care to

primary care• More time on education and support

and advice for primary care• More time for intensified care for

appropriate patients,

Complex needs, Transition.

ALL - Involvement planning integrated care Closer Working relationship

What What does this mean for Patients?

Complete care by adequately trained professionals

Local care

Consistent care

Access to specialist advice

Seen in most appropriate care setting

Involvement in planning and monitoring integrated care

Early lessons

in developing and delivering integrated care for a population – diabetes

• It takes time• Shared vision, leadership and purpose• Education, education, education• Devolved management and decision making• Multi-agency planning – patient involvement• Use external influencers• Appropriate specialist care depends on a skilled primary

care workforce• Recognise variation

The journey – The journey – Bolton to Boston and backBolton to Boston and back

Why?Why?

What?What?

Bolton to BostonBolton to Boston - Objectives

• To learn theory and practice of quality improvement techniques in healthcare

• To become an “expert” in the delivery of chronic disease care by– Studying and exploring current theory– Observing systems and current practice in US and elsewhere – Particular emphasis on integration, and learning from one

disease area for others

• Develop capacity and skills leadership and facilitation

Boston and beyond

• IHI and (HSPH)– Formal and informal learning of QI– Interacting with many healthcare systems, leaders and clinical

teams– Worked with clinical teams in collaborative learning (Office

Practice, Quality Allies, BPHC)

• Visited healthcare systems and opinion leaders to explore the delivery of chronic disease care

• Shared learning and growth through fellowship

IHI examples

• 100,000 lives campaign – 80 % of American hospitals working to reduce mortality

• BPHC – 900 community based clinics for “underserved”, collaboratives in diabetes, depression, finance, clinic transformation

• Kaiser Permanente – A Kaiser model for spreading best practice– Improving primary care by innovative use of IT

• RWJF - Transforming care at the bedside,

• IMPACT - Emergency redesign, Flow, Reliability,

• GLOBAL – HIV aids SA, Botswana, Tanzania– Maternal Mortality , malawi

McColl institute, McColl institute, Group Health, Group Health,

Virginia Mason, Virginia Mason, Everett ClinicEverett Clinic

Kaiser Permanente Kaiser Permanente (CMI), Life Masters, (CMI), Life Masters, Stanford University Stanford University Patient EducationPatient Education

Kaiser Permanente, Kaiser Permanente, Southern CASouthern CA

Alaska Native Alaska Native Health CareHealth Care

Geisinger Geisinger HealthHealth

Veterans Veterans Administration Administration

ConnecticutConnecticut

Maine Health, Maine Health, Dartmouth Dartmouth HitchcockHitchcock

Cambridge Health Cambridge Health Alliance, MGH, Alliance, MGH, Joslin Clinic, Beth Joslin Clinic, Beth Israel Deaconess, Israel Deaconess, VA Massachusetts, VA Massachusetts, Renaissance HealthRenaissance Health

Clinical Teams Clinical Teams throughout the country in throughout the country in

CollaborativesCollaboratives

Health Partners, Health Partners, Park Nicollett, Park Nicollett, Mayo ClinicsMayo Clinics

Personal Learning • As healthcare professionals we try and manage disease

rather than trying to enable people with long term conditions to live their lives as fully as possible.

• There are well described models and approaches to improving care, that it can’t be achieved by education and planning alone

• That many health service structures inhibit the development, delivery and improvement of appropriate care

• That these obstructions are common to most health systems but potentially least within the NHS than any other health system in the world

Specific Learning

Quality Improvement• Many methods and approaches, widely used and systemic in US• Need to develop a learning organisation with quality as a key strategy and

goal, from leadership to micro-system• Start with measurement and feedback, and small simple changes

Chronic Care• Very widespread use of “The Chronic Care Model” but only components.• Generally UK “ahead” of US

- registries, primary care, specialist involvement, multidisciplinary working• US more use of “Power of patient peers”• Multiple approaches to Care/Case management/Care coordination• Boundaries of current care in UK and US are integration of care

How to improve care of people with long term conditions

Healthcare Healthcare Organisation Organisation

leadershipleadership

PopulationPopulationregistriesregistries CompositionComposition

of care teamof care team

Self Self management management

educationeducation

Self Self ManagementManagement

supportsupport

Decision Decision supportsupport

Community Community resourcesresources

CommunityCommunityawarenessawareness

Planned Planned carecare

PatientPatientCentredCentred

consultationconsultationShared Shared DecisionDecisionmakingmaking

BehaviourBehaviourChange/Change/

MotivationalMotivationalinterviewinginterviewing Skills Skills

requirements requirements for patientsfor patients

and practitionersand practitioners

Use of ITUse of IT

Care Care coordinationcoordination

Case Case managementmanagement

AdvocacyAdvocacyPatientPatientactivationactivation

Putting it all togetherPutting it all together

Current methods

• The Chronic Care Model http://www.improvingchronicillnesscare.org

• Planned Care http://www.ihi.org/IHI/Results/WhitePapers/InnovationsinPlanned+CareWhitePaper.htm

• The medical home (children)Paediatrics 2004 113(5) 1545-1547

““Planned Care”Planned Care”

• Planned care is the term used in the US for care that results from the chronic care model

• The key elements for clinical teams are:– Disease Registers Aiming at optimal care for all

– Planned Care Visit (individual or group)

– Self Management Support Incorporating self management education, goal setting and action planning

Remaining challenge is integrating care

• Integrating care across professional/organisational divides between specialists and generalists

• Integrating care across conditions and needs for people with multiple conditions

Chronic Care ModelChronic Care Model

Health Care OrganizationHealth Care Organization

Care TeamCare Team

Designed Designed Personal CarePersonal Care

Clinical Clinical InteractionInteraction

Clinical Clinical MethodMethod

Three Tiered Approach to Care for Long Term Conditions

Health care organisations

• Health Care Organisation • Clinical Information Systems• Delivery System Design• Self Management Support• Decision Support• Community

Use the framework of Chronic Care Model

to support clinical teams and clinical interactions

The two key cycles in designed care for people with long term conditions

1. The population care cycle• Planned use of registers

2. The designed personal care cycle• Designing effective patient specific care

Population planning cycle

Ensure robustEnsure robust mechanisms mechanisms for populating for populating

registerregister with desiredwith desired

measuresmeasures

Pre-visit Pre-visit assessmentassessment

of care needsof care needs

Planned review Planned review of population forof population for

•Data quality Data quality • Gaps in careGaps in care•Status reportStatus report

•Population aimsPopulation aims

Call and RecallCall and Recall for designedfor designed

carecare

Principles of population planning cycles

• Care for the population is a fundamental component of chronic care

• Active management of population registers is required

• A measurement strategy is needed to monitor care outcomes

• Population register management must be linked to clinical care

• Roles of clinical team members in population management need defining, and their time to fulfill this role planned and protected

• Plan regular team review of registry data

• Regular team based review of population care should lead to continuous improvement of care delivery and outcomes

Collaborative care plan• Goals

• Personal action plans•Self Management education

• Treatment• Support/care team

• Review and follow up

Continuing review and support as per care plan

•Where•When•How

•By whom

Planned Assessments

•What•Where•How

•When•How often

Designed Personal Care Cycle for continuing care

The concept of care cycles for designed personal care

• Care for chronic conditions is a continuous process that has a number of repeated elements

• Certain elements of care should be delivered at a predetermined frequency

• Assessment is essential to inform care planning

• Typical care cycles can be designed for specific diseases or parts of the population, but are then modified or combined for a personal care cycle

• Separating components of care into elements of care cycles helps clinical teams and patients to plan – reliable care, – the role of members of the care team,– the location or mode of each component of care

Members of the Care Team for people with long term conditions

• Patient• Patient’s family and significant others• Primary Care Physician• Other clinical members of the primary care team • Non clinical members of the primary care team• Specialist clinicians• Peer advisors/mentors

Essential roles to be assigned in the care team are:CARE COORDINATOR, ADVOCATE, KEY CONTACT

Collaborative care plan•Goals and action plans

•Self management education•Treatment

•Support/care team•Review

Continuing education, treatment

and review as per care plan

Screening for presence of complications. Retinopathy, Foot problems, Proteinuria and Microalbuminuria, Cardiovascular Disease,

Serum Creatinine

Treatment of Diabetes Complications

“Annual Assessment” Risk factor assessment for complications, HbA1c, Lipids, Blood Pressure, Smoking Status, Body Weight/ (BMI/Waist circumference)

Assessment of treatments, Medicines Management, Hypoglycaemia assessment and advice, Insulin use and injection site assessment

Knowledge and Self Care Assessment including glucose monitoring and nutritional assessment

Psychological well being assessmentDental AssessmentSexual Health Assessment

Designed Personal Care Cycle for Diabetes

Clinic A






Functional Assessment e.g. walking distance

Risk factor assessment, Smoking Status, Body Weight (BMI/Waist circumference)

Cardiovascular AssessmentBlood Pressure, Lipids

Assessment of treatments, Medicines Management,

Knowledge and Self Care Assessment including use of devices, self care plan. Emergency care plan

Psychological well being assessment

Designed Personal Care Cycle for COPD

Physiological Assessment

Vitalograph, O2 Saturation






Presence of diabetes complications – Screening. Retinopathy, Foot problems, Proteinuria and Microalbuminuria,

Cardiovascular Disease, Serum Creatinine Screening StudiesColonoscopy, PSA, UrinalysisPhysiological /Functional AssessmentVitalograph, O2 Sats, walking distance

Treatment of Diabetes Complications

“Annual Assessment” Risk factor assessment for complications, HbA1c, Lipids, Blood Pressure, Smoking Status, Body Weight/(BMI/Waist circumference)

Assessment of treatments, Medicines Management, Hypoglycaemia assessment and advice, Insulin use and injection site assessment

Knowledge and Self Care Assessment including glucose monitoring and nutritional assessment,

Emergency care plan

Psychological well being assessmentSexual Health Assessment

Vaccination: Flu, Pneumovax, Dental Assessment

Designed Personal Care Cycle for

65 Man with Diabetes and COPD

Personalising Care cycles

Segmentation• Classically we segment the population and care needs by diagnosis,

“control” of the disease, age or racial background

• Different intensities and types of care are required for different parts of the population

• When designing typical care cycles, teams should consider how they will segment the population, and how the cycles will vary. This is the first step in personalising care cycles and can be matched to the available resources

• Using other measures, such as confidence to self care, or a measure of patient activation as well as biomedical “disease control” to define care needs should be considered.

Chronic Care ModelChronic Care Model

Health Care OrganizationHealth Care Organization

Care TeamCare Team

Designed Designed Personal CarePersonal Care

Clinical Clinical InteractionInteraction

Clinical Clinical MethodMethod

Three Tiered Approach to Care for Long Term Conditions

Clinical Care Needs

The Old• Single acute curable

disease

• One to one doctor/patient interaction

• Face to face individual care

• Dominant physician role

The New• Multiple chronic disease

• Healthcare teams, group visits, joint appointments,

peer led education

• Telephone, email, web based, population care and self care

• Partnership between care givers and activated patient and family

• Describes the skills and tools that clinicians and patients need for effective assessment and collaborative care planning

• Describes specific methods for certain care needs e.g. joint consultation, clinical team functions, telephone care, email care, self assessment, group care

Clinical Interface

Use “Clinical Method for Chronic Disease” Use “Clinical Method for Chronic Disease” for patient centered carefor patient centered care

Clinical Interface

Collaborative Care• Relationship building• Understanding the whole person• Agenda setting• Assessment and problem solving

(includes barriers to self care, and self assessment)

• Education (teach back)• Shared decision making• Goal setting and action planning

(includes barriers)• Agreeing the care team, follow up

and support

Care team functions • Advocacy• Access• Care coordination• Coaching

Use “Clinical Method for Chronic Disease” for patient centered care

Health System Performance in Selected Nations

Compiled by Katherine K. Shea, Alyssa L. Holmgren,Robin Osborn, and Cathy Schoen. May 2007

2004 Commonwealth Fund International Health Policy Survey of Adults' Experiences with Primary Care. (8,500 adults)

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (7000 adults)

2006 International Health Policy Survey of Primary Care Doctors (5000 docs)

OECD Health Data from 2004 and 2005


Health Care Organisation: • Improving care for long term conditions must be a strategic priority.• Negotiations with payers to fund effective preventive care for people

with long term conditions• Advanced access should be a policy for primary and specialist care



US UK

Multiple organisations and models, differing priorities.

LTC are an NHS priority at national and local level

Separation of payer and provider can bring misaligned incentives

Single payer, devolved to PCT/PBC, QuOF, payment systems need to evolve further for LTC, current PBR not appropriate

Many working on advanced access as good in competitive market

Advanced access achieved for primary care, but not always with right member of care team

Waited More than Four Weeksto See a Specialist Doctor, Sicker Adults, 2005

22 23

4046

57 60

0

25

50

75

100

GER US NZ AUS CAN UK

Percent

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Base: Saw or needed to see a specialist


Clinical Information Systems:

• The organisation should use IT for disease registers, and produce comparative measured outcome with facilitated feedback

• EMR with patient portal for access, and reliable information• Rapid referral through EMR or email



US UK

Integrated healthcare systems increasingly using single EMR, but many do not include registers. Much of primary care not “computerised”.

EMR and registers are “ a way of life” in primary care. Rarely integrated with specialist care.

Where used, register data is worked for quality improvement, some payers insist on data

QuOF data available, used for payment and ? QI on primary care.

Where EMR present patient portal engaging patients in care, email etc used for consultation and referral

My Healthspace, developing but rudimentary, little email consultation or referral

Capacity to Generate Patient Information, 2006

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

2637

81

63

80

68

92

25

37

55 59

72 74

88

0

25

50

75

100

CAN US GER NET NZ AUS UK

List of patients by diagnosis

List of patients' medications, including Rx by other doctors

Percent of primary care practices reporting very or somewhat easy to generate

828

61

9383

18

14

3265

5

16

24

20

18

0

25

50

75

100

AUS CAN GER NET NZ UK US

Y es, using a manual systemY es, using a computerized system

Physicians Reporting Routinely Sending Patients Reminder Notice for Preventive or Follow-Up Care, 2006

Percent of physicians


Physicians’ Reports on Availability of Data on Clinical Outcomes or

Performance, 2006

Percent of physicians reporting yes:


Patients’ clinical outcomes

36 24 71 37 54 78 43

Surveys of patient satisfaction and experiences

29 11 27 16 33 89 48


Primary Care Doctors Use of Electronic Patient Medical Records, 2006

9892 89

79

42

2823

0

25

50

75

100

NET NZ UK AUS GER US CAN



J Am Board Fam Med 2007;20:299 –306.

Table 4. Percentage of DHK’s Patients Who Were Present Throughout the Study, Who Achieved Optimal Diabetes Care Goals (n 43)

Quarter LDL <100 A1c <7 % BP <130 Aspirin Tobacco Free All 51 in 2004 42 46 65 56 56 24 in 2005 79 54 84 100 91 46

ODC, optimal diabetes control; LDL, low-density lipoproteins; BP, blood pressure.

Allina Medical Clinics Enterprise SummaryPercentage of Patients with Diabetes in Optimal Control

2006-2007

11.5%12.6%

13.6%14.4%

15.2%16.1%

17.1% 17.6%

18.9%

20.6%

21.9%

0%

5%

10%

15%

20%

25%

30%

June July Aug Sept Oct Nov Dec Jan Feb Mar Apr

GOAL


Delivery System Design:• Supports multidisciplinary care, with extended roles of care team

members including care/case management/care coordination etc• Incorporates patients and families into care design• Has service agreements between departments• Leads an integrated approach for close working of primary care and

specialists



US UK

Payment systems do not support multidisciplinary care, tightly defined professional boundaries

Well developed multidisciplinary teams within primary and specialist care, working in extended roles

Case management hugely variable in approach

Case management for vulnerable a national target, varying models developing

Physician-Reported Use of Multi-Disciplinary Teams and Non-Physicians, 2006


Practice routinely uses multi-disciplinary teams:

Yes 32 32 49 50 30 81 29

Practice routinely uses clinicians other than doctors to:

Help manage patients with multiple chronic diseases

38 25 62 46 57 73 36

Non-physicians provide primary care services

38 22 56 33 51 70 39


Case/care management

• Every health system has a different approach

• Health Partners and Geisinger, Case Managers from Payer, monitoring care and coordinating care by phone to minimise cost and delays

• VHA, Phone centre coordinating care, linked to disease specific case managers, practice based case managers, and community nurses

• Kaiser Permanente, role akin to specialist nurses, diabetes and heart failure

• Maine Health, roles akin to practice nurses

Key roles: advocacy, care planning, care co-ordination, self management education


Self Management Support:• Provides access to Self management skills education programmes, and supports

lay educators• Ensures access to information and education resources for patients and families• Enables training of the MDT in “clinical method for chronic disease”• Provides patient held record• Enables multi disciplinary team to give continuing support and advocacy

including non visit methods



US UK

Well developed disease specific education programmes, supported by payers

Sporadic access and take up despite EPP, one to one education but unstructured

Sicker Adults with Hypertension or DiabetesWho Received Recommended Care by

Self-Management Plan or Nurse Involvement, 2005

6167

50

68 64

7974 78 77 81

8691

0

50

100

NZ AUS UK CAN US GER

Neither self-management plan or nurse Self-management plan and/or nurse

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Includes blood pressure and cholesterol for hypertension; Hemoglobin A1cand cholesterol checked, and feet and eyes examined for diabetes

Percent


Decision Support:• Ensures guidelines etc, incorporated into EMR or register with

reminder function• Stepped approach to specialist care, with easy access to specialists

for advice



US UK

Where EMR well developed generally supported by decision support, but variable e.g. VHA

NICE, national knowledge centre, map of medicine etc

Stepped Specialist Role in Care for people with chronic conditions

Level 1• Specialist helps to define best practice (guidelines/protocols)

Level 2• Patient does not easily fit the guideline, brief discussion with

specialist required by phone, email, informal consult

Level 3• More detailed review of the case is required with the specialist as

multiple decisions are needed or the case is more complex. This will be by case note review or joint consultation

Level 4• The patient requires detailed face to face assessment by the

specialist team members, and may require a period of continuing specialist care. This will be by referral

2340

8093 87 91

6 6

10

3128

33

102

0

25

50

75

100

CAN US GER AUS NET NZ UK

Y es, using a manual systemY es, using a computerized system

Doctors Reporting Routinely Receiving Alerts about Potential Problem with Drug Dose/Interaction




Community:• Develops service agreements with other organisations• Identifies community resources and establishes service agreements• Develops and supports links to employers• Develops and supports links to social care



US UK

Extremely variable, examples of good practice

Generally not well developed but should do through “Our health, our care, our say”

Employers take responsibility for health care

Employer responsibility and resource generally underused

Overall Ranking

AUSTRALIA CANADA GERMANYNEW

ZEALANDUNITED

KINGDOMUNITEDSTATES

OVERALL RANKING (2007) 3.5 5 2 3.5 1 6

Quality Care 4 6 2.5 2.5 1 5

Right Care 5 6 3 4 2 1

Safe Care 4 5 1 3 2 6

Coordinated Care 3 6 4 2 1 5

Patient-Centered Care 3 6 2 1 4 5

Access 3 5 1 2 4 6

Efficiency 4 5 3 2 1 6

Equity 2 5 4 3 1 6

Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6

Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102

* 2003 dataSource: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard.

Three Tiered Approach to Continuous Quality Improvement

Leadership Leadership priority for priority for

qualiltyqualilty

Individual skills and willIndividual skills and will

to improveto improve

Teams have clear aims, Teams have clear aims, measurement and support measurement and support

for improvementfor improvement

Alig

nmen

t

Alig

nmen

t Alignm

ent

Alignm

ent

Summary so far -

• Developed an integrated diabetes service– Multi agency planning - Shared vision, leadership

– Skill up primary, appropriate role of specialists – Devolved management and decision making– Work with some variation in primary care– Recognise variation

• Learning from Experts– Lessons apply across diseases– Challenge is integration– Roles of HCO, Clinical teams, skill development

• NHS has essential building blocks for excellence in LTC care

Applying lessons locally

Diabetes• Re-establish the network in “patient led NHS”• Change the model,

– all fundamental care in primary care. – skills for collaborative care planning– specialist care for intensive care management– systems to support 4 step approach to specialist

care• Develop QI potential

– Aims, measures, skills, culture

Commissioning quality care for people with Long Term

Conditions• Has to be a whole system approach

• Common principles can be applied to all LTC

• Local models of care must be described, and acknowledged by all stakeholders

• Measurement systems must be defined

• Strong role of networks in advising, integrating, educating and monitoring- linking with PBC. Gives ownership.

• “Corporate roles of commissioners”Standards, IT, training, interface issues, measurement and feedback, change agents

PCT Strategy for LTC

Care teams– Primary care focussed for multi-disciplinary, patient

centred, planned population care (registers)– Specialist role –supporting primary care, managing

complex patients at time of increased need– Case management approach - “Medical Home”

(Intensity of care based on clinical need,

Planned care related to individual need)– Integrated health and social care (including voluntary

groups/employers)


Patient Centred Care– Support self-management– Patient and clinician engagement in care

development and assessment – Collaborative care planning

– Patient owned information– Culturally sensitive services


• Accessible and Timely Services– Integrated smoothing transitions– Named Contact– Advocates

• Quality improvement– Measures for quality improvement linked to health

Improvement

• Addressing Inequalities– Care targeted and designed to meet population need– Focus on areas of high morbidity

Steps in integrated care design

• Define priorities, and principles• Stakeholder engagement• Agree Model• Commission services• Local Clinical Network established

– Clarify pathways– Work across interfaces– Monitor and address standards/QI– Skills development

Components of care

Presentation Diagnosis Severity assessment

Initial education and treatment

Structured self management education

Continuing planned care dependant on severity

Exacerbation

Step up care

MaintenancePalliative Care

PREVENTION

COPD/CCF

CCF/COPD

• Skill up primary care and fill the gaps– CDM Team• Levels of care (as per diabetes)• Focus on high morbidity areas• Identification of COPD, (PBC)• Self Management Education cardio/pulmonary• Case management at differing levels of intensity for CCF• Clarify Pathways – Network Group

• End of life care

Neurological Conditions

• Rapid assessment and treatment service

• Integrated chronic disease management– Case Management approach– Multidisciplinary teams, integrating health,

social care, employment– Define Medical Home dependent on

complexity

Lessons from NHSto others

Population approach to care

Public Health integrated into healthcare

PCT – remit of improving health and healthcare for population

Universal access

Strong Skilled Multidisciplinary Primary Care

Clear guidance on best practice

Accessible specialist care

Population Healthcare

Health

Cost per capita

Experience of care

Building blocks in place Now -

Integrate primary, specialist and social careWidespread structured education for self managementBroaden case management approachAccess through care coordinator Patient involvement in designing careSkills for collaborative care planning

Target high morbidity areas

Clear Aims, Measures and culture of continuous improvementInformation management

Clinical LeadershipBetter alignment of incentives

dr john d dean, md frcp

Documents

patients primary care

nhsdiabetes care

town centre diabetes

bolton primary care

specialist interaction

primary careexternal

primary caremore practice

boltonfully integrated