The Advanced Primary Practitioner Project,

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The Advanced Primary Practitioner
Project, Modernisation in Practice
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What is Evercare?

• Started in the US 15 years ago 60,000 elderly in
  15 states in nursing homes and in the community
  (numbers in the community doubled over past few
  years)
• Provides enhanced medical care and coordination
  of services for the elderly
• Clinical programme where doctors,
  specially-trained nurses and care staff work
  together collaboratively
• Improved Patient Outcomes Better quality care
• Reduced need for urgent medical care
• 50 less hospital admissions
• Reduction in drugs polypharmacy
• 97 satisfaction rating in GPs reduction in
  calls to GP

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The Quality of Life Gap
Quality of Life Gap
Declining Health (Current)
Increasing Morbidity
Managed Chronic Disease
Age 65 75 85 95
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Delivering Results

• Advanced Primary Practitioners
• Learning Research
• WIC/LTC
• Investing in Your Health
• (Investment)

• Reduce spend on CDM
• Managed system
• ability to plan care needs
• Pts in control (partners
• in care) healthier population
• (Delivery)

• Clinical assessment service
• Remodelling services
• Practice based commissioning
• Choice
• (Reform)

Efficiency / Effectiveness

• Source
• Gus ODonnell, Permanent Secretary to DoH 2004

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• The Solution made in Luton
• The right care given
• In the right place
• At the right time
• By the right people

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Our strengths
Provider Services
Not for profit
Patient
Build on this unique combination
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Today 2 of the elderly population in Luton (775
patients) occupy - 70 of all elderly
beds - Nearly 50 of all the beds in LD 60 of
all deaths are due to chronic disease 31 of
South Asians suffer from diabetes
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• The Solution - made in Luton
• 24 hour Advanced Primary Practitioner service to
  the population of acutely chronically ill people
  of Luton serving initially 1444 people rising to
  2700 by 2009/10
• Delivering
• A reduction of 50 emergency hospital admissions
  (for this group)
• A reduction in GP consultations by 10
• A 30 reduction in hospital length of stay
• ..

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3 Dimensional Integration
Self-referral and primary care referral
Drop-in with some booked group sessions
Acute minor injury ailments
Walk in Centre
Mainly 11
Single encounter
Nurse-led
Nurse-led
Treatment Centre
Self-referral and primary secondary care
Long-term case management
Mainly booked appointments
Multi-disciplinary assessment
Chronic disease
Short/long term
Prevention management of chronic conditions
Advanced Primary Practitioners Pilot
Term approach
11 and with carers/families
Case management anticipatory care
Primary and secondary care
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The Solution made in Luton

• A service taking the best principles of
• Evercare
• Kaiser
• Intermediate care
• Sub acute care

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The Reality

• Advanced Primary Practitioners 13 Nurses, 1
  Pharmacist a Pharmacy technician
• GP practices on board
• 900 Patients identified and assessments
  completed
• Competency programme
• Validation of Masters Module
• Base at Luton Treatment Centre for Chronic
  Disease Management

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Advanced Primary Practitioner Service

• Piloted May 2003 to October 2004
• Commissioned December 2004
• Currently providing care to 900 patients
• Fully implemented by 2009/10 providing care
• to 2,700 patients

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Results

• Reductions in emergency admissions 67 in the
  350 original cohort
• Within the P2 cohort of COPD patients reductions
  in emergency admissions are 60
• Polypharmacy 83 had two or more medicines
  removed in their tertiary level medicines
  management review
• Currently reductions in emergency admissions for
  the cohort of 900 patients is 62
• In comparator years the GP undertook a chest and
  heart examination on average twice a year. The
  APPs on an amber (at risk) patient will undertake
  the same examination a minimum of twice a month
• Reduction of number of GP visits by 74 in
  cohort of 900

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The Future

• Practitioner integration with communities
• Community nursing
• Health Visiting
• Palliative care
• Intermediate Care
• Independent contractors
• Pharmacists
• Ophthalmologists
• Not for profit orgs

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A Service

• Patient Centred
• Evidence Driven
• Delivering Results
• Which are metrics based
• Which Alice summed up as
• My life has changed, I feel happy again, I
  havent been this well for years

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Given the multi-dimensional nature of chronic
illness care this model needs to be adopted by
the whole system, stakeholders from community
social and health care services organisation
being the key to effective delivery. Managing
Chronic Diseases, R M Davis, E H Wagner, T
Groves, BMJ 1999 318 1090-1091
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Some Key Evidence Sources

• DH compendium of chronic disease management, 2004
• Health and quality of life outcomes
  www.hqlo.com. Predicting declines in physical
  function in persons with multiple chronic medical
  conditions, Bayliss et al
• Chronic Disease Management in the UK. Looking to
  the future, Sue Roberts, www.natpact.nhs.uk
• Reduction of hospital utilisation in patients
  with chronic obstructive pulmonary disease a
  disease specific self management intervention,
  Intern Med 2003, Bourbeau et al
• Reducing emergency visits in older adults with
  chronic illness a randomised controlled trial of
  group visits Effective Clinical Practice,
  Coleman et al