CHRONIC DISEASE MANAGEMENT TEAM

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CHRONIC DISEASE MANAGEMENT TEAM

• Claire Hurlin
• Coordinator
• Carmarthenshire LHB

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• Background
• WAG involvement
• Objectives
• Criteria / Eligibility
• CMD Team today
• Whats next

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Department of Health 2004 stated

• Account for up to 80 GP consultations
• 60 of hospital bed days are for patients with
  chronic disease or related complications
• Two thirds of patients admitted as medical
  emergencies have exacerbation of chronic disease,
  or have chronic disease
• 10 of inpatients account for 55 of inpatient
  days

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Better care packages for patients with chronic
disease

• More support for self management by patients
• More structured visits and follow up
• Use of clinical information systems
• Clear generic model of chronic disease management
  linking the macro policy environment to frontline
  care and the needs of patients
• BMJ 2004

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In Wales

• Wales has a higher proportion of reported
  limiting long-term illness (23) compared with
  England (18), Scotland and Northern Ireland
  (20)
• 1/3 of adults report having at least one chronic
  condition
• 2/3 of over 65 year olds report having at least
  one chronic condition with 1/3 having multiple
  chronic conditions
• 3/4 of over 85 year olds report having a limiting
  long-term illness

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• The most commonly reported chronic condition
  treated in Wales is arthritis (14), followed by
  respiratory (13) and chronic heart condition
  (9)
• Intensive users of in patient services have on
  average 3 chronic conditions
• It is estimated that by 2014 there will be a 12
  increase in adults with at least one chronic
  condition
• and 20 increase in those over 65

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Chronic Disease Management
Intensive Rehabilitation
To enable independence
Pressure on hospital beds earlier discharge
Canllaw Community Intermediate Care Service
Early intervention and Education
VICIOUS CYCLE
Insufficient rehabilitation
Chronic Disease Management
Adapted from the Audit Commissions (2000) The
Way to Go Home
Rising Emergency Admissions
Admission to Institutional Care Less resources
for preventative care
Self Management Education
Rapid Response
Acute Response Teams
24 hour 7 day a week
Chronic Disease Management
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Papers recommending changes in the way Healthcare
is delivered in Wales

• Health and Social Care Review (Wanless) July 2003
• Designed for Life May 2005
• Carmarthenshire Health and Social Care Well being
  Strategy 2005 (new 2008)
• Designed to Deliver 2006
• Chronic Conditions Management Model and Framework
  2007

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The Welsh Chronic Conditions Model
Chronic Disease Management Team
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Objectives of CDM Team

• Advising patients on self management.
• Identifying patients at risk of a crisis or
  exacerbation.
• Providing care to prevent emergency admissions.
• Providing education on chronic disease management
  for patients/carers/relatives in particular COPD,
  Diabetes and Heart Failure.

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• Educating and supporting health professionals in
  the community.
• Improving access to health care for hard to
  reach/disadvantaged groups.
• Supporting community projects that encourage
  healthy lifestyles.

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The Eligibility criteria to access the CDM Team
is-

• Adults aged 18 years and over
• The patient lives within Carmarthenshire
• The patient has given consent to be
• reviewed by the CDM Team
• The patient fulfils the criteria set out for
  referring to the CDM Team

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Presently

• Work 9am 5pm
• Monday Friday
• No weekends
• Information packs given out every G.P. in
  Carmarthenshire
• Information packs given out to all Medical ward
  sisters, AE and AMAU
• Information packs given to district nurses

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Chronic disease management within
Carmarthenshire
3 WTE, H/F nurses H grade
3 WTE, Diabetic nurses
2 WTE, COPD nurses 1 WTE Physio
CDM Team
Llanelli area
Amman valley
Carmarthen area

• 1 H/F,
• 1 Diabetic
• 1 COPD,

• 1 H/F,
• 1 Diabetic
• 1 COPD

• 1 H/F,
• 1 Diabetic
• 1 COPD

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Access to CDM, COPD Team

• COPD diagnosis is confirmed by spirometry
• On optimal therapy as per NICE guidelines COPD
  continuing to deteriorate

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• AND includes at least one of the following
• The patient is for discharge post acute admission
  to hospital
• The patient has had multiple exacerbations in
  previous 12 months
• The patients is currently receiving a high number
  of drugs on repeat prescriptions in need of a
  medication review

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Access to CDM, Diabetes Team

• Access is by direct referral from GP, consultant,
  diabetic nurse, practice or district nurse
  provided the following criteria are met
• Confirmed diagnosis of Diabetes (as per WHO
  diagnostic Criteria)
• People with Type II Diabetes

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• Hard to reach groups i.e.
• Residential/Nursing Homes
• Sheltered Accommodation
• Day Care Centre
• Housebound
• Post MI patients
• Frequent Admissions
• Persistent DNAs

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Access to CDM, Heart Failure Team

• Access is by direct referral from GP, Consultant,
  Heart Failure nurse, practice or district nurse
  provided the following criteria are met
• Confirmed documented diagnosis of Heart Failure
• Heart Failure Caused by Left Ventricular Systolic
  Dysfunction

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• Documentation of -
• Echo if available
• Urea and Electrolytes
• CXR report
• ECG
• Full Blood Count
  
• Glucose
• Thyroid Function Test
• Lipids
• Urinalysis
• Spirometry (if appropriate)

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Two SaFF targets set by LHB for CDM Team

• 10 reduction in emergency medical
  re-admissions against a 2004/2005 baseline
• 10 reduction in the number of bed days
  resulting from emergency medical admissions
  against a 2004/2005 baseline. Target date 31st
  March 2007.
• (Includes Canllaw and ART)

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CDM Team Today Referrals
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COPD Referrals
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Diabetes Referrals
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Heart Failure Referrals
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Emergency Medical Admissions(General Medicine,
Cardiology, and Geriatrics)
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What have we achieved

• Local heart failure nurse led clinics
  Crosshands, Amman Valley, Llandovery, Whitland,
  Newcastle Emlyn as well as PPH and WWGH
• Training on diabetes for nursing homes and
  residential homes with annual updates
• Achieved and bettered target of 44 admission
  avoidances per month
• Integrated Care Pathways (ICPs)

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• Better Breathing Project
• Self Care and Support Database
• Diabetes X-pert structured education programme
• Heart Failure education plans
• COPD education DVD
• Staff education
• - Chronic Conditions
  Module, University of Wales, Swansea
• - Warwick diabetes diploma
  
• - Heart Failure Diploma
  

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In COPD, an audit has been undertaken looking at
admissions one year pre referral and up to one
year post referral to the CDM COPD Team.

• The results show of the 298 patients audited
  there were 60 deaths of which 13 died in
  hospital.
• The totals mean number of admissions pre 1.56,
  post 1.46.
• At 3 months pre 0.59 post 0.29.
• At 6 months pre 0.90 and post 0.54.
• At 12 months pre 1.59 post 1.65
• Total mean number of bed days pre 13.5 post
  7.83.
• At 3 months pre 6.85 post 3.19
• At 6 months pre 10.12 post 4.46
• At 12 months 14.74 post 11.78

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Carer questionnaire comments

• Comments made by Carers
• When I started to care for my partner I was
  worried If I was doing the right thing but the
  team have given me so much support I do not feel
  alone as I get all the help I need
• The office staff are always cheerful and the best
  thing that they pass on the correct message for a
  fast response.

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• I do not know what I would have done without the
  team for the past two years. I hope funding will
  always be in place for them.

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Patient questionnaire

• Without this team I would have been in hospital
  several times and being at home means that I
  recover so much quicker than in hospital. The
  team is a great liaison between GP, Specialist
  and the patient and a great relief as a source of
  anxiety, relief and care. The country would
  benefit greatly if this type of team was rolled
  out nationally.

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• I think it is an excellent service. I was able to
  leave hospital quicker than on previous occasions
  as they visited me at home
• The CDM team is a wonderful thing. It takes
  stress out of illness and keeps me out of
  hospital. And the rehab was the icing on the
  cake. I was a different person after it. The
  staff in every department is so nice and helpful.
  May the service last a long time and if there is
  anything I can do to help the cause please ask.

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What next?

• Demonstrator Site to implement CCM Framework
• Principal Project Manager
• Review current services
• Look for good practice
• Look for gaps
• Action Plan
• Report to WAG 3 monthly
• Patient and Public involvement

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Community care includes CDM, ART, Canllaw
Primary care
Secondary care
Patient and Public Involvement
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Thank youCDM Team Carmarthenshire LHB

• Telephone Number01554 744464
• Fax Number01554 744488