Developing services for patients with long term conditions

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Developing services for patients with long term
conditions 
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Content

• Background and context
• Stratifying patients at risk of admission
• Commissioning appropriate services to manage
  chronic disease
• Cost benefits to the PCT of better case
  management
• Lessons for the future

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Background

• Initiated in 2004/05
• In response to increasing levels of non elective
  bed usage
• Recognition that it was not confined to care of
  the elderly
• Life expectancy improving but quality of life
  dependent on ability to manage LTC effectively
• Better understanding of our share of the 17m
  people nationally living with a LTC

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The population

• What do we know about the people populating the 3
  tier triangle?
• What is the data telling us?
• What about the knowledge in primary care?

Kaiser Permanente triangle
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Chronic Disease ManagementData to support risk
stratification for population management model
SW PCT
These are based on data from a bed usage
survey undertaken on 17th July 2004. The Survey
included all adult inpatients in medical,
orthopaedic and selected surgical specialties
those in care home placements currently
identified for intermediate care. The
survey Involved 1078 patients, 213 of which
were SW PCT patients.
Level 3 Highly complex patients As people
develop more than one chronic condition
(co-morbidities), their care becomes
disproportionately more complex and difficult for
them, or the health and social care system, to
manage. This calls for case management with a
key worker (often a nurse) actively managing and
joining up care for these people.
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Source ONS PH Mortality
Level 3
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Level 2 High risk patients Disease/care
management, in which multidisciplinary teams
provide high quality evidence based care to
patients, is appropriate for the majority of
people at this level. This means proactive
management of care, following agreed protocols
and pathways for managing specific diseases. It
is underpinned by good information systems
patient registries, care planning, shared
electronic health records.
Number of discharges 2003/04
Number of discharges 2003/04
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Level 2
Level 170-80 of CDM Population With the right
support many people can learn to be active
participants in their own care, living with and
managing their conditions. This can help them to
prevent complications, slow down deterioration,
and avoid getting further conditions. The
majority of people with chronic conditions fall
into this category so even small improvements
can have a huge impact.
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QMAS prevalence data not currently available
Level 1
Source 2001 Census
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Level 1 70-80 of CDM Population
What did we know then?

• Approximately 22,000 people reporting a long term
  limiting illness
• Increasing in prevalence with age
• 17,500 at Level 1 -self management

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Level 1 nowutilising QOF data
QOF data and prevalence modelling gives us a more
accurate picture of the main chronic diseases
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Possible commissioned services for Level 1

• Huge potential impact
• Expert Patient programmes
• Health promotion programmes
• Targeted interventions, e.g. smoking cessation

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Level 2 - Higher riskCDM primary diagnosis ICD
Codes

• Non elective admissions as proxy for higher risk
• List of main chronic conditions included
• Chronic diseases only account for 1/3 of
  admissions
• Significant source of hospital activity in under
  65 age group

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Level 2 Higher risk patients Non elective
activity chronic disease

• Information on numbers of people, their age,
  number of admissions and length of stay
• Non elective chronic disease in under 65 shows
  significant bed occupancy
• Results in a average length of stay of nearly 3
  weeks

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Possible commissioned services and actions for
Level 2

• Improving patient registers
• Establish case finding mechanism to identify at
  risk
• Implement agreed pathway for each condition
• Identify key workers to be responsible for at
  risk patient
• Responsive and timely coordinated
  multidisciplinary approach to exacerbation

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Level 3 ComplexMultiple Non elective admissions

• Majority of admissions single
• At GP practice level no of 2 admissions
  translates into manageable number of identifiable
  people( 25-30)

2 admissions 406 people (15)
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Level 3 complex needs
Balance of care study
Social care

• Poor routinely collected data sources
• Indication of complex care needs , co-
  morbidities and multiple drug therapies

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Level 3 - End of life

• Useful proxy of numbers at level 3
• Implications for palliative care if shift from
  hospital to more end of life care at home

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Possible commissioned services and action for
Level 3

• Community matrons co-ordinating care input to
  meet complex needs
• Proactive implementation of evidence based
  packages of care for condition
• Community based end of life/palliative care

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What we did with this analysis?

• Visit each GP practice with their own triangle
• Gather staff views of their data and their
  approach to managing long term conditions
• Bring back ideas for next steps

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GP Practice reaction

• What can you (the PCT) tell us (GPs) about these
  patients?
• Who are they and how did they get there?
• We want to understand it better

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PCT response

• Identifying patient named data for people meeting
  agreed criteria inc. 2 non elective admissions
• Data filtered and passed to District nurse teams
  and GP
• Review, referral and action identified

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Developing the approach further

• Improving our understanding of the prevalence of
  chronic disease
• Identifying people at risk from data and
  clinicians
• Segmenting the population e.g. COPD -mild,
  moderate, and severe
• Targeting appropriate interventions in PHC

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Identify the caseload
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Caseload management

• Focus intervention where we know we can make a
  difference
• Learning to let go discharge from caseload
• Simplifying access to support for GPs/ staff who
  identify someone at risk
• Flagging as at risk and linking with other
  information systems

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Using data to target development work
register
Prescribing behaviour
QoF COPD management
Emergency admissions for COPD
Population characteristics
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Development plan

• Improving case registration
• Support PHC to develop best practice in COPD
  management
• Developing services to prevent exacerbation and
  support management in PHC
• Targeted self management programme
• Optimise prescribing pattern for COPD

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Learning

• Wealth of available data but how best to use it
• Data in the right place, in the right format, at
  the right time
• Many of the people at risk not known to PCT
  staff
• Reason for admission - diagnostic coding vs. HRGs
  vs. GP read codes
• Service redesign to refocus community staff
  effort
• Attribution of impact of intervention to change
  in hospital activity levels

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New model

• Informed and shaped by population analysis and
  segmentation
• Population at risk identified, engaged and
  monitored
• Patients and carers attune with early
  identification of problems and self management.
• Specialist expertise accessible to support PHC
  management and develop skills base with staff
• Single point of access to support for PHC and
  patients/carers

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Moral?

• The only thing that gives an organisation a
  competitive edge the only thing that is
  sustainable is what it knows, how it uses what
  it knows, and how fast it can know something
  new!
• Prusak, 1996