Long Term Conditions Long Term Conditions CollaborativeCollaborative & T10& T10

Marjorie McGintyMarjorie McGinty

1010THTH Dec 09Dec 09

Thank YouThank You……

Opportunity to talk to you about the LTCCPOpportunity to talk to you about the LTCCPChance to listen to your views about how we Chance to listen to your views about how we in LTCCP can work with EADT on delivering in LTCCP can work with EADT on delivering T10T10

Rising at all agesRising at all ages……People reporting a chronic condition (by age)

0

10

20

30

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50

60

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1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002

Year (note: data from1998 is w eighted)

% o

f sam

ple

0-4y

5-15y

16-44y

45-64y

65-74y

75+

Population of Scotland -Christmas tree to Super Tanker

By 2030 incidence of By 2030 incidence of LTCsLTCs in the in the over 65s will have doubledover 65s will have doubled

Implications of aging populationImplications of aging population

We are more likely to:We are more likely to:live alonelive alonehave functional dependency and sensory have functional dependency and sensory impairmentimpairmenthave a long term conditionhave a long term conditionhave cohave co--morbiditymorbidityhave cognitive impairmenthave cognitive impairment

We are more likely to:We are more likely to:take multiple medications take multiple medications develop complications of acute illnessdevelop complications of acute illnessdevelop infectiondevelop infectionstay longer in hospitalstay longer in hospitalrequire rehabilitationrequire rehabilitation

Long Term ConditionLong Term Condition

““Condition that requires ongoing medical care, Condition that requires ongoing medical care, limits what one can do, and is likely to last limits what one can do, and is likely to last

longer than one year.longer than one year.””NHS Scotland 2005NHS Scotland 2005

Population modelPopulation model

Professional CareSelf Care

Care Care ManagementManagement

DiseaseDisease ManagementManagement

Supported Supported Self CareSelf Care

Level 3Level 3Complex coComplex co--morbidity morbidity 3 3 –– 5%5%

Level 2Level 2Poorly controlled single Poorly controlled single disease 15 disease 15 –– 20%20%

Level 1Level 1Well controlled Well controlled (70(70--80% of LTC 80% of LTC population)population)

Population Wide Prevention, Health Improvement & Health Promotion

LTCC LTCC WorkstreamsWorkstreams

Self ManagementSelf Management Condition ManagementCondition Management

Complex CareComplex Care Information & EvaluationInformation & Evaluation

Complex Care Complex Care improvement actions which will provide the best quality of care improvement actions which will provide the best quality of care and support for and support for

people with complex health and social care needs.people with complex health and social care needs.

Integrated Care ManagementIntegrated Care ManagementCare Homes SupportCare Homes SupportPalliative Care (malignant & non Palliative Care (malignant & non malignant)malignant)Anticipatory Care PlansAnticipatory Care PlansCommunity HospitalsCommunity HospitalsRehabilitationRehabilitation

Integrated Care ManagementIntegrated Care Management

Proactive, Planned and Proactive, Planned and CoordinatedCoordinated

DefinitionDefinition

Department of health asDepartment of health as““ a proactive approach focused on higha proactive approach focused on high--

risk patients with a combination of risk patients with a combination of medical, nursing, pharmaceutical care medical, nursing, pharmaceutical care and social care needs.and social care needs.””

NHS Lanarkshire calls thisNHS Lanarkshire calls this““Integrated Care ManagementIntegrated Care Management””

ConceptConcept

Is not just about changing the way we Is not just about changing the way we deliver care. It is about a change in our deliver care. It is about a change in our thinking, our behaviour and our culture, as thinking, our behaviour and our culture, as we move towards truly holistic care.we move towards truly holistic care.Focused on over 65 year olds with complex Focused on over 65 year olds with complex care needs.care needs.PurposePurpose to enable people with complex to enable people with complex care needs to be cared for within their care needs to be cared for within their preferred home environmentpreferred home environment

“The biggest problem for patients and carers is that feeling of being lost, they come out of hospital and maybe if their relationship breaks down, or something isn’t identified for social work input, then they are on their own again and they don’t know where to go, so to have this constant help and support is just great for the more vulnerable patients and carers especially.”

Who is a Care Manager?Who is a Care Manager?

Qualified, experienced Community Nurses Qualified, experienced Community Nurses who have additional skills and trainingwho have additional skills and trainingCare managers assess, design and deliver Care managers assess, design and deliver a personalised care plan for each individual a personalised care plan for each individual on their case load that they are Care on their case load that they are Care Managing. Managing. They coThey co--ordinate the patients journey ordinate the patients journey through health and social services by acting through health and social services by acting as a Key worker.as a Key worker.

What does it involve?What does it involve?Full assessment medical, nursing, Full assessment medical, nursing, pharmaceutical and social care needspharmaceutical and social care needsDevelop Develop personalisedpersonalised holistic care plansholistic care plansInvolve patients and Involve patients and carerscarers as partnersas partnersHighly visibleHighly visibleLead roleLead roleSecure services/ treatments modalitiesSecure services/ treatments modalitiesTeach pt/ Teach pt/ carerscarers monitor conditionmonitor conditionMaintain contact throughout hospital Maintain contact throughout hospital admissionsadmissionsCross boundary workingCross boundary working

Proactive Case FindingProactive Case FindingSScottish cottish PPatients atients AAt t RRisk of isk of RReadmission eadmission

and and AAdmissiondmission

LLanarkshireanarkshireIIdentification ofdentification ofVVulnerableulnerableEElderlylderlyToolTool

Clinical JudgementClinical Judgement

Potential BenefitsPotential BenefitsBetter outcomes for individuals, Better outcomes for individuals, their families, carers and their families, carers and communitiescommunitiesImproved access to servicesImproved access to servicesReduction in the use of Reduction in the use of unplanned careunplanned careImproved concordance with Improved concordance with medicationmedicationImproved partnership workingImproved partnership workingReduction in the number of Reduction in the number of professionals involved in the professionals involved in the individuals careindividuals care

Improved choiceImproved choiceGreater continuity of support / Greater continuity of support / care / involvementcare / involvementMore control in the package of More control in the package of care / support providedcare / support providedImproved and speedier decision Improved and speedier decision makingmakingEmpowerment of individual Empowerment of individual through active participation in through active participation in the processthe process

Progress Mar Progress Mar –– Sept 09Sept 09

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700

March May July Sept

Patients

Case StudyCase Study

Case StudyCase Study

Mrs A is a 76 year old Mrs A is a 76 year old lady identified as lady identified as having a 76% risk of having a 76% risk of hospital admissionhospital admission

Reason for admission Reason for admission --symptoms of ill defined symptoms of ill defined conditioncondition

DN visit and assessment resultsDN visit and assessment results

Medical HistoryMedical History-- GPASSGPASSDementiaDementiaArthritisArthritisCHDCHDPernicious AnaemiaPernicious Anaemia

Social HistorySocial HistoryLives alone in a cottage flatLives alone in a cottage flatHas family that live nearby.Has family that live nearby.

Allocated to a community mental health team.Allocated to a community mental health team.Has had a single shared assessment undertaken Has had a single shared assessment undertaken by social work department and has a package of by social work department and has a package of care in place 7 days a week 4 times a day to help care in place 7 days a week 4 times a day to help with personal care and meals.with personal care and meals.Hospital discharge letters Hospital discharge letters ––reveal the reason for reveal the reason for hospital admissions were for pain (8 admissions) hospital admissions were for pain (8 admissions) and all were in the out of hours period and through and all were in the out of hours period and through NHS 24NHS 24

Current service involvementCurrent service involvement--PIMSPIMS

Next Step Next Step -- InputInputCommunity Nurse Community Nurse arranges date and time to arranges date and time to visitvisitMrs A fully mobileMrs A fully mobileVariety of carers Variety of carers attendingattendingWent to local bingo and Went to local bingo and keep fit clubkeep fit clubPersonal care assistancePersonal care assistanceMedication reviewMedication reviewEnvironment assessmentEnvironment assessment

ProcessProcess

Social work Family

GPCommunity

mental health team

Pharmacy

PatientCare

Manager

Liaise

Monitored dose box

interaction

medication

pensionfinance

carers

Pain relief

OutputsOutputs

Pharmacy assessment

Monitored dosage box for medication

was now prepared that Mrs A son

would collect weekly.

Social Work assessmentReassessed the care package

and changed carers to experienced carers in

people with dementia

OutputsOutputs

Son took over responsibility for finance with support from social worker who

maximised Mrs A benefits

Family

Re started visits and increased opportunities

for social interactions for Mrs ACPN

OutcomesOutcomes

No more hospital No more hospital admissions for Mrs Aadmissions for Mrs A

Pain is now controlled Pain is now controlled and she is able to and she is able to sleep at night.sleep at night.

Independence has Independence has been preservedbeen preserved

How can Integrated Care How can Integrated Care Management help reduce A&E Management help reduce A&E

attendances?attendances?

Care Managed patients & A&E Care Managed patients & A&E attendanceattendance

All patients being care managed added to A&E All patients being care managed added to A&E system (EDIS)system (EDIS)Updated monthly by LTCC Information ManagerUpdated monthly by LTCC Information ManagerA&E staff can see flag that patient being care A&E staff can see flag that patient being care managed, name and managed, name and teltel no. of care managerno. of care managerStaff able to contact care manager to discuss Staff able to contact care manager to discuss patients condition and support availablepatients condition and support availableStarted on 1Started on 1stst Dec for 3 month periodDec for 3 month periodWeekly review and analysis of care managed Weekly review and analysis of care managed patients attendingpatients attending

11stst --66thth Dec (week 1)Dec (week 1)

Wed Wed –– SunSun11 patients being care managed attended A&E11 patients being care managed attended A&E5 in hours, 6 out of hours period5 in hours, 6 out of hours period5 GP Direct Admissions5 GP Direct Admissions6 attendances 6 attendances –– 5 sent home, 1 admitted5 sent home, 1 admitted–– Pain x 3Pain x 3–– PR BleedingPR Bleeding–– COPDCOPD–– UnknownUnknown

So whatSo what……??

Encourage communication between Care Encourage communication between Care Managers and A&E staffManagers and A&E staffReview benefit of this communication, does Review benefit of this communication, does it reduce A&E attendances?it reduce A&E attendances?Encourage communication between Care Encourage communication between Care Managers and ward staffManagers and ward staffReview benefit of this communication, does Review benefit of this communication, does it reduce LOS?it reduce LOS?

Anticipatory Care PlansAnticipatory Care Plans

Thinking AheadThinking Ahead

What is an Anticipatory Care Plan?What is an Anticipatory Care Plan?

Anticipatory Care Plans (Anticipatory Care Plans (ACPsACPs) can help patients ) can help patients plan for the future. plan for the future. The term falls under the umbrella of Advance Care The term falls under the umbrella of Advance Care Planning and provides the opportunity to think Planning and provides the opportunity to think about, talk about and write down preferences and about, talk about and write down preferences and priorities for care. priorities for care. The process is voluntary and the discussion is The process is voluntary and the discussion is entered into only if the patient wishes to do so.entered into only if the patient wishes to do so.

Why do we need them?Why do we need them?

An ACP can help patients and their families An ACP can help patients and their families understand what is important to them when understand what is important to them when planning care, especially if it is their wish to planning care, especially if it is their wish to be cared for at home and to stay at home, be cared for at home and to stay at home, avoiding any unnecessary hospital journeys avoiding any unnecessary hospital journeys or admissions.or admissions.

Development of Development of ACPsACPs in NHSLin NHSLNHS Lanarkshire has developed an ACP that includes a clinical NHS Lanarkshire has developed an ACP that includes a clinical component. component. Working with the patient and their families to look out for sympWorking with the patient and their families to look out for symptoms toms that may indicate a change in their condition and providing guidthat may indicate a change in their condition and providing guidance on ance on what action to take should this occur.what action to take should this occur.

An ACP is the personal property of the patient but can involve aAn ACP is the personal property of the patient but can involve anumber of agencies. Therefore during the development process NHnumber of agencies. Therefore during the development process NHS S Lanarkshire has been as inclusive as possible. Lanarkshire has been as inclusive as possible.

A multi agency expert working group was convened in late 2008 toA multi agency expert working group was convened in late 2008 todevelop the ACP, guidance notes, patient and develop the ACP, guidance notes, patient and carercarer information, and a information, and a teaching package that would support the ongoing and sustainable teaching package that would support the ongoing and sustainable implementation.implementation.

To support ACP useTo support ACP use

Patient Information LeafletPatient Information LeafletCarer Information LeafletCarer Information LeafletGuidance Notes for staffGuidance Notes for staffTeaching Package for staff Teaching Package for staff –– e.g. DVDe.g. DVD

Pilot SitesPilot SitesSummer Lee House Care Home Summer Lee House Care Home CoatbridgeCoatbridgePark Springs Care HomePark Springs Care Home MotherwellMotherwellGreenhillGreenhill’’s Care Home s Care Home BiggarBiggarWhitehillsWhitehills Care HomeCare Home East East KilbrideKilbrideMeldrum Gardens Care Home Meldrum Gardens Care Home East East KilbrideKilbrideMckillopMckillop Care Home Care Home East East KilbrideKilbrideMcWhirtersMcWhirters Care Home Care Home East East KilbrideKilbrideDewar House Care Home Dewar House Care Home Hamilton Hamilton CanderavonCanderavon Care HomeCare Home StonehouseStonehouse

EvaluationEvaluation

PersonPersonRelatives/CarersRelatives/CarersCare Home StaffCare Home StaffNHS LanarkshireNHS LanarkshireQualitative Qualitative –– experience of those involved, experience of those involved, benefits and impact on thembenefits and impact on themQuantitative Quantitative –– robust data to support and robust data to support and evidence the impactevidence the impact

How can Anticipatory Care Plans How can Anticipatory Care Plans help reduce A&E attendances?help reduce A&E attendances?

TestingTesting

100 100 ACPsACPs being used in 9 Care Homes over a one being used in 9 Care Homes over a one month period (July)month period (July)17 turned around within 24hrs of attending A&E 17 turned around within 24hrs of attending A&E (and did not re(and did not re--attend)attend)12 avoided hospital admission (as a result of 12 avoided hospital admission (as a result of having ACP)having ACP)5 people died in their preferred place of death (as 5 people died in their preferred place of death (as a result of having an ACP)a result of having an ACP)Tracking patients with an ACP to monitor effect on Tracking patients with an ACP to monitor effect on A&EA&E