Description
Definitions and types of chronic diseases and methods of chronic disease management CDM alongwith examples of cases and chronic case model.
Chronic Diseases Management
Chronic diseases are problems which current medical interventions can only control not cure.
The life of a person with a chronic condition is forever altered - there is no return to “normal”.
I don't always look after myself all the time … The truth is I am scared about the long term, I'm scared of going blind or having my legs chopped off. Self management is the cornerstone of diabetes care, however, you don't need to be an `expert patient' to take control of your own diabetes. You need a relationship with the right professionals to help you understand all the issues, make the right decisions, and achieve the right balance."
What is it like having a chronic disease?
Interview with Stuart Bootle, a GP who has had diabetes for 20 years
The number of people with chronic conditions is rising
(Source; General Household Survey 2002)
All people reporting a chronic condition
36 35 34 33 32 31 30
Percent
35 33 32 32
31
30 29
28 26 24 22 21 20 1972 1975 1981 1985 1991 1995 Year 1996 1998 1998 2000 2001 2002 24
(note: data from 1998 is weighted)
And rising at all ages
People reporting a chronic condition (by age)
80 70
60 50
% of sample
0-4y 5-15y 16-44y 45-64y 65-74y 75+
40 30 20
10 0
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from1998 is w eighted)
And it is likely to continue rising because
The commonest chronic diseases are arthritis and rheumatism, and heart problems (including high blood pressure).
30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 28.0% 16.8% 13.5% 11.2% 8.9% 8.5% 8.2% 7.9% 5.1% 4.0% 3.5%
(Source BHPS 2002)
S ki en n ta lh ea lt h D D iff ig ic es ul t iv ty H e ea in da he ch ar in es g an V d is m ua ... lp ro bl em s S tro ke D ia be te s M
rth H ea rit is rt et (in c. c hi gh B P R ) es pi ra to ry
A
In the UK of those people with a long standing problem around a quarter have 3 or more problems, making care far more complex.
Proportion of people with a chronic disease with 3 or more problems
74% 3 or more problems 1 or 2 problems 26%
(Source; British Household Panel Survey 2001)
Women are slightly more prone to report chronic conditions; social class has a bigger impact though…
(source General Household Survey 2002)
% people with a longstanding problem
45% 40% 35% 30% 25% 20% Manual worker Intermediate worker Managerial and professional worker 34% 32% Women Men 41% 40%
30% 30%
Chronic disease is probably the wrong term, as most people with longstanding medical conditions also have other complex needs leading to other disabilities often requiring care from other sources, especially social care.
% of people with activity limitations
80 70 60 50 40 30 20 10 0 67 52 42 28 15 4 None one two three four 5+
percent
number of chronic diseases
Many people have more than one chronic condition
Average number of chronic conditions (for those with a chronic condition)
[Source General Household Survey 2002]
2
Number of conditions
1.8 1.6 1.4 1.2 1 16-44 45-64 Age 1.3 1.5
1.7
1.8
65-74
75+
How is the NHS currently configured and what problems does this create?
“The predominant acute disease paradigm is an anachronism. It is shaped on a 19th century notion of illness as a disruption of the normal state produced by a foreign presence or external trauma,... Under this model acute care is that which directly addresses the threat. …. In fact, modern epidemiology shows that the prevalent health problems of today (defined both in terms of cost and health impact) revolve around chronic illness.” Bob Kane
i
acute and chronic conditions
Onset Duration Cause Diagnosis and prognosis Technological intervention Outcome Uncertainty Knowledge Acute disease Abrupt Limited Usually single Usually accurate Usually effective Cure possible Minimal Professionals knowledgeable, patients inexperienced Chronic illness Generally gradual and often insidious Lengthy and indefinite Usually multiple and changes over time Often uncertain Often indecisive; adverse effects common No cure Pervasive Professionals and patients have complementary knowledge and experiences
i
Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ. 2000; 320: 526-527
Having one or more chronic conditions increases your need for health care disproportionately
Increased likelihood of needing to use health services with increasing no.s of chronic problems
Ratio compared to no problems
5 4 3 2 1 0 GP consultations Inpatient days No problems 1 or 2 problems 3 or more problems
And in some cases a few patients with chronic conditions end up on the “revolving door”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
1.00
Cumulative percentage of inpatient days
0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0.00
5% of patients account for 42% of bed use
10% of patients account for 55% of bed use
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Percentage of inpatients
What can we do?
Level 3
Highly Case Management complex patients Specialist Disease Management
Level 2
High risk patients
Supporting care And Self Care
Level 1
70-80% of a Chronic disease pop
Self-care works
? visits to GPs can reduce by over 40% for high risk groups
Fries J et al (1998) Reducing need and demand for medical services in high risk groups. West J Med 169: 201-207.
? hospital admissions reduce by 50% in a Parkinson’s disease
Montgomery et al (1994) Patient education and health promotion can be effective in Parkinson's disease: a randomised control trial. The American Journal of Medicine Vol. 97: 429.
? outpatient visits reduce by 17% generally
Lorig et al (1985) A work place health education programme that reduces outpatient visits. Medical care 23, No 9: 1044-1054.
? hospital length of stay reduce for mental health problems
Kennedy M (1990). Psychiatric Hospitalizations of Growers. Paper presented at the Second Biennial Conference on Community Research and Action, East Lansing, Michigan.
? medication intake more appropriate (e.g. steroids in asthma)
Charlton et al (1990) Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice BMJ 301: 1355-9.
? A&E visits reduce significantly for patients with asthma
Choy et al (1999) Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socio-economic status in Hong Kong. Clinical Experimental Allergy 29: 84-90.
? days off work can reduce by as much as 50% for people with arthritis
Supporting chronic care
To do this we need to consider the Three Rs; ?Registration of a population of patients for whom primary care teams identify problems, co-ordinate care and help support their condition. ?Recall of people to ensure they get the care they need by using prompts and reminders. ?Review patients to ensure they receive the best evidence based care and are supported to manage their condition
Supporting chronic care
For most patients this care will come from • their general practice • community nurses • pharmacists • other members of the wider PCHT
Some patients with chronic conditions need more
• Some have a chronic condition that needs the occasional input of a specialist- often a community based (nurse) specialist- to avoid deteriorations and improve control: disease specific case management • Others have a complex mix of social and medical problems, often leading to frequent re-admissions, unless they receive case management
Disease specific case management
There is good evidence about the impact of responsive community specialist services on specific conditions, for example heart failure COPD and asthma diabetes
Department of Health. National Service Framework for Coronary Heart Disease. HMSO, 2000.And Doughty RN, Wright SP, Pearl A, Walsh HJ, Muncaster S, Whalley GA et al.
Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. Eur Heart J 2002;23:139-46.And Knox D,.Mischke L. Implementing a congestive heart failure disease management program to decrease length of stay and cost. J Cardiovasc Nurs 1999;14:55-74.And Stewart S, Blue L, Walker A, Morrison C, McMurray JJ. An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it? Eur Heart J 2002;23:1369-78.
Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease:
a disease-specific self-management intervention. Arch Intern Med 2003;163:585-91.And Morrison DS,.McLoone P. Changing patterns of hospital admission for asthma, 1981-97. Thorax 2001;56:687-90.And Baker D, Middleton E, Campbell S. The impact of chronic disease management in primary care on inequality in asthma severity. J Public Health Med 2002;25:258-60.And Naish J, Sturdy P, Griffiths C, Toon P. Appropriate prescribing in asthma. BMJ 1995;310:1472.And Barbanel D, Eldridge S, Griffiths C. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. Thorax 2003;58:851-4.And Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA) [In Process Citation]. BMJ 2004;328:144.
Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database
Syst Rev 2001;CD001481.And Sidorov J, Gabbay R, Harris R, Shull RD, Girolami S, Tomcavage J et al. Disease management for diabetes mellitus: impact on hemoglobin A1c. Am J Manag Care 2000;6:1217-26.And Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R. Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria. Diabetes Care 2002;25:684-9.And Vrijhoef HJ, Spreeuwenberg C, Eijkelberg IM, Wolffenbuttel BH, van Merode GG. Adoption of disease management model for diabetes in region of Maastricht. BMJ 2001;323:983-5.
and depression
Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J et al. Disease management for depression and at-risk drinking via telephone in an older population of veterans.
Psychosom Med 2003;65:931-7.And Coyne JC, Brown G, Datto C, Bruce ML, Schulberg HC, Katz I. The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study. Int J Geriatr Psychiatry 2001;16:570-6.And Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002;325:951-4.And Roberts K, Cockerham TR, Waugh WJ. An innovative approach to managing depression: focus on HEDIS standards. J Healthc Qual 2002;24:11-64.
Case management
For some patients a more holistic approach is required. They are often highly intensive users, or very highly intensive users of the health service, and simple problems amenable to early interventions (e.g. a fall or an acute infection) can lead to a rapid deterioration in their condition.
It is these people that largely make up the “5%”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
1.00
Cumulative percentage of inpatient days
0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0.00
5% of patients account for 42% of bed use
10% of patients account for 55% of bed use
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Percentage of inpatients
Case management
Before Case management
Initially presented in A&E 4 times over the last 3 months with falls Care package, meals on wheels and personal alarm in situ At risk of recurrent falls, poor transfer technique Unable to access community transport or mobilise outdoors Oedema in both lower legs Older person felt lonely, isolated and depressed – “I tell people what I need but they don’t hear me”.
After Case management
Easy-Care Assessment in own home. Listened to her voice and spent time understanding her needs. Contacted GP and District Nurse to review medication and to deliver incontinence pads. Spent time together to ensure receiving appropriate benefits. Arranged for mobile hairdresser and for ears to be pierced. Carried out a joint assessment with the Occupational Therapist. Put air into tyres of old wheelchair
How does it fit together? The Chronic Care Model
i
i
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.
PCTs need to work in partnership with other NHS Trusts (including ambulance trusts) and social care to develop integrated approaches to care. A key issue is the sharing of incentives to promote high quality care. PCTs need local strategic partnerships with local authorities, engaging community and voluntary organisations Many of the pieces are in place: The Expert Patient programme, NHS Direct and digital TV pilots, but some is patchy. We should build on the strengths of multidisciplinary team working (including social care) with a strong centre in primary care. The NHS could increase its use of risk stratification and case management of high risk patients.
26
Remember the three Rs: IT should can support care planning, risk stratification, and monitoring the quality of care on offer. Information systems need to support the transfer of information.
We must build on the use of evidence based guidelines for the treatment of chronic diseases and incorporate them in IT systems to make it easier to do the right thing.
New GMS and PMS: The New GMS and PMS: The quality and outcomes quality and outcomes framework rewards good framework rewards good CDM in ten important CDM in ten important diseases. diseases. PMS+ and enhanced services PMS+ and enhanced services gives PCTs the ability to build gives PCTs the ability to build capacity for new chronic capacity for new chronic disease services disease services
Set of tools in each health community to create a health and social care system to support people with a chronic problem
IT: Already the information IT: Already the information systems are in place for systems are in place for Registration, Recall, and Review. Registration, Recall, and Review. At risk patient can be identified. At risk patient can be identified. The NPfIT will augment this and The NPfIT will augment this and help the flow of information help the flow of information
DH Chronic Disease Management; the growing problem
27
Other potential tools...
Develop communit y clinical Practice specialist incentives and (nurse led) commissionin teams g
Ensure savings Commissio made in one n care part of the through system clinical benefit all networks involved in chronic care
Integrat e with social care, more intermediate care
Use defined clinical care pathway s
Health care communities and the NHS as whole benefit because investing in chronic disease reaps
health and financial dividends .
The Wanless report, Securing Our Future Health (Interim Report) argued that for every pound invested in self care;
around £1.50 can be reinvested more effectively The economic case for disease management is more complex, but the improvement in quality of life is undeniable. There is a growing evidence base on the possible financial effects of case management (mainly from abroad, but increasingly from the UK). This suggests that investing in primary and community care to support case management will free up scarce acute resources to use more appropriately.
DH Chronic Disease Management; the growing problem 29
The NHS moves from…
doc_906184852.ppt
Definitions and types of chronic diseases and methods of chronic disease management CDM alongwith examples of cases and chronic case model.
Chronic Diseases Management
Chronic diseases are problems which current medical interventions can only control not cure.
The life of a person with a chronic condition is forever altered - there is no return to “normal”.
I don't always look after myself all the time … The truth is I am scared about the long term, I'm scared of going blind or having my legs chopped off. Self management is the cornerstone of diabetes care, however, you don't need to be an `expert patient' to take control of your own diabetes. You need a relationship with the right professionals to help you understand all the issues, make the right decisions, and achieve the right balance."
What is it like having a chronic disease?
Interview with Stuart Bootle, a GP who has had diabetes for 20 years
The number of people with chronic conditions is rising
(Source; General Household Survey 2002)
All people reporting a chronic condition
36 35 34 33 32 31 30
Percent
35 33 32 32
31
30 29
28 26 24 22 21 20 1972 1975 1981 1985 1991 1995 Year 1996 1998 1998 2000 2001 2002 24
(note: data from 1998 is weighted)
And rising at all ages
People reporting a chronic condition (by age)
80 70
60 50
% of sample
0-4y 5-15y 16-44y 45-64y 65-74y 75+
40 30 20
10 0
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from1998 is w eighted)
And it is likely to continue rising because
The commonest chronic diseases are arthritis and rheumatism, and heart problems (including high blood pressure).
30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 28.0% 16.8% 13.5% 11.2% 8.9% 8.5% 8.2% 7.9% 5.1% 4.0% 3.5%
(Source BHPS 2002)
S ki en n ta lh ea lt h D D iff ig ic es ul t iv ty H e ea in da he ch ar in es g an V d is m ua ... lp ro bl em s S tro ke D ia be te s M
rth H ea rit is rt et (in c. c hi gh B P R ) es pi ra to ry
A
In the UK of those people with a long standing problem around a quarter have 3 or more problems, making care far more complex.
Proportion of people with a chronic disease with 3 or more problems
74% 3 or more problems 1 or 2 problems 26%
(Source; British Household Panel Survey 2001)
Women are slightly more prone to report chronic conditions; social class has a bigger impact though…
(source General Household Survey 2002)
% people with a longstanding problem
45% 40% 35% 30% 25% 20% Manual worker Intermediate worker Managerial and professional worker 34% 32% Women Men 41% 40%
30% 30%
Chronic disease is probably the wrong term, as most people with longstanding medical conditions also have other complex needs leading to other disabilities often requiring care from other sources, especially social care.
% of people with activity limitations
80 70 60 50 40 30 20 10 0 67 52 42 28 15 4 None one two three four 5+
percent
number of chronic diseases
Many people have more than one chronic condition
Average number of chronic conditions (for those with a chronic condition)
[Source General Household Survey 2002]
2
Number of conditions
1.8 1.6 1.4 1.2 1 16-44 45-64 Age 1.3 1.5
1.7
1.8
65-74
75+
How is the NHS currently configured and what problems does this create?
“The predominant acute disease paradigm is an anachronism. It is shaped on a 19th century notion of illness as a disruption of the normal state produced by a foreign presence or external trauma,... Under this model acute care is that which directly addresses the threat. …. In fact, modern epidemiology shows that the prevalent health problems of today (defined both in terms of cost and health impact) revolve around chronic illness.” Bob Kane
i
acute and chronic conditions
Onset Duration Cause Diagnosis and prognosis Technological intervention Outcome Uncertainty Knowledge Acute disease Abrupt Limited Usually single Usually accurate Usually effective Cure possible Minimal Professionals knowledgeable, patients inexperienced Chronic illness Generally gradual and often insidious Lengthy and indefinite Usually multiple and changes over time Often uncertain Often indecisive; adverse effects common No cure Pervasive Professionals and patients have complementary knowledge and experiences
i
Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ. 2000; 320: 526-527
Having one or more chronic conditions increases your need for health care disproportionately
Increased likelihood of needing to use health services with increasing no.s of chronic problems
Ratio compared to no problems
5 4 3 2 1 0 GP consultations Inpatient days No problems 1 or 2 problems 3 or more problems
And in some cases a few patients with chronic conditions end up on the “revolving door”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
1.00
Cumulative percentage of inpatient days
0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0.00
5% of patients account for 42% of bed use
10% of patients account for 55% of bed use
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Percentage of inpatients
What can we do?
Level 3
Highly Case Management complex patients Specialist Disease Management
Level 2
High risk patients
Supporting care And Self Care
Level 1
70-80% of a Chronic disease pop
Self-care works
? visits to GPs can reduce by over 40% for high risk groups
Fries J et al (1998) Reducing need and demand for medical services in high risk groups. West J Med 169: 201-207.
? hospital admissions reduce by 50% in a Parkinson’s disease
Montgomery et al (1994) Patient education and health promotion can be effective in Parkinson's disease: a randomised control trial. The American Journal of Medicine Vol. 97: 429.
? outpatient visits reduce by 17% generally
Lorig et al (1985) A work place health education programme that reduces outpatient visits. Medical care 23, No 9: 1044-1054.
? hospital length of stay reduce for mental health problems
Kennedy M (1990). Psychiatric Hospitalizations of Growers. Paper presented at the Second Biennial Conference on Community Research and Action, East Lansing, Michigan.
? medication intake more appropriate (e.g. steroids in asthma)
Charlton et al (1990) Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice BMJ 301: 1355-9.
? A&E visits reduce significantly for patients with asthma
Choy et al (1999) Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socio-economic status in Hong Kong. Clinical Experimental Allergy 29: 84-90.
? days off work can reduce by as much as 50% for people with arthritis
Supporting chronic care
To do this we need to consider the Three Rs; ?Registration of a population of patients for whom primary care teams identify problems, co-ordinate care and help support their condition. ?Recall of people to ensure they get the care they need by using prompts and reminders. ?Review patients to ensure they receive the best evidence based care and are supported to manage their condition
Supporting chronic care
For most patients this care will come from • their general practice • community nurses • pharmacists • other members of the wider PCHT
Some patients with chronic conditions need more
• Some have a chronic condition that needs the occasional input of a specialist- often a community based (nurse) specialist- to avoid deteriorations and improve control: disease specific case management • Others have a complex mix of social and medical problems, often leading to frequent re-admissions, unless they receive case management
Disease specific case management
There is good evidence about the impact of responsive community specialist services on specific conditions, for example heart failure COPD and asthma diabetes
Department of Health. National Service Framework for Coronary Heart Disease. HMSO, 2000.And Doughty RN, Wright SP, Pearl A, Walsh HJ, Muncaster S, Whalley GA et al.
Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. Eur Heart J 2002;23:139-46.And Knox D,.Mischke L. Implementing a congestive heart failure disease management program to decrease length of stay and cost. J Cardiovasc Nurs 1999;14:55-74.And Stewart S, Blue L, Walker A, Morrison C, McMurray JJ. An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it? Eur Heart J 2002;23:1369-78.
Bourbeau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease:
a disease-specific self-management intervention. Arch Intern Med 2003;163:585-91.And Morrison DS,.McLoone P. Changing patterns of hospital admission for asthma, 1981-97. Thorax 2001;56:687-90.And Baker D, Middleton E, Campbell S. The impact of chronic disease management in primary care on inequality in asthma severity. J Public Health Med 2002;25:258-60.And Naish J, Sturdy P, Griffiths C, Toon P. Appropriate prescribing in asthma. BMJ 1995;310:1472.And Barbanel D, Eldridge S, Griffiths C. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. Thorax 2003;58:851-4.And Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA) [In Process Citation]. BMJ 2004;328:144.
Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database
Syst Rev 2001;CD001481.And Sidorov J, Gabbay R, Harris R, Shull RD, Girolami S, Tomcavage J et al. Disease management for diabetes mellitus: impact on hemoglobin A1c. Am J Manag Care 2000;6:1217-26.And Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R. Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria. Diabetes Care 2002;25:684-9.And Vrijhoef HJ, Spreeuwenberg C, Eijkelberg IM, Wolffenbuttel BH, van Merode GG. Adoption of disease management model for diabetes in region of Maastricht. BMJ 2001;323:983-5.
and depression
Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J et al. Disease management for depression and at-risk drinking via telephone in an older population of veterans.
Psychosom Med 2003;65:931-7.And Coyne JC, Brown G, Datto C, Bruce ML, Schulberg HC, Katz I. The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study. Int J Geriatr Psychiatry 2001;16:570-6.And Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002;325:951-4.And Roberts K, Cockerham TR, Waugh WJ. An innovative approach to managing depression: focus on HEDIS standards. J Healthc Qual 2002;24:11-64.
Case management
For some patients a more holistic approach is required. They are often highly intensive users, or very highly intensive users of the health service, and simple problems amenable to early interventions (e.g. a fall or an acute infection) can lead to a rapid deterioration in their condition.
It is these people that largely make up the “5%”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
1.00
Cumulative percentage of inpatient days
0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0.00
5% of patients account for 42% of bed use
10% of patients account for 55% of bed use
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Percentage of inpatients
Case management
Before Case management
Initially presented in A&E 4 times over the last 3 months with falls Care package, meals on wheels and personal alarm in situ At risk of recurrent falls, poor transfer technique Unable to access community transport or mobilise outdoors Oedema in both lower legs Older person felt lonely, isolated and depressed – “I tell people what I need but they don’t hear me”.
After Case management
Easy-Care Assessment in own home. Listened to her voice and spent time understanding her needs. Contacted GP and District Nurse to review medication and to deliver incontinence pads. Spent time together to ensure receiving appropriate benefits. Arranged for mobile hairdresser and for ears to be pierced. Carried out a joint assessment with the Occupational Therapist. Put air into tyres of old wheelchair
How does it fit together? The Chronic Care Model
i
i
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.
PCTs need to work in partnership with other NHS Trusts (including ambulance trusts) and social care to develop integrated approaches to care. A key issue is the sharing of incentives to promote high quality care. PCTs need local strategic partnerships with local authorities, engaging community and voluntary organisations Many of the pieces are in place: The Expert Patient programme, NHS Direct and digital TV pilots, but some is patchy. We should build on the strengths of multidisciplinary team working (including social care) with a strong centre in primary care. The NHS could increase its use of risk stratification and case management of high risk patients.
26
Remember the three Rs: IT should can support care planning, risk stratification, and monitoring the quality of care on offer. Information systems need to support the transfer of information.
We must build on the use of evidence based guidelines for the treatment of chronic diseases and incorporate them in IT systems to make it easier to do the right thing.
New GMS and PMS: The New GMS and PMS: The quality and outcomes quality and outcomes framework rewards good framework rewards good CDM in ten important CDM in ten important diseases. diseases. PMS+ and enhanced services PMS+ and enhanced services gives PCTs the ability to build gives PCTs the ability to build capacity for new chronic capacity for new chronic disease services disease services
Set of tools in each health community to create a health and social care system to support people with a chronic problem
IT: Already the information IT: Already the information systems are in place for systems are in place for Registration, Recall, and Review. Registration, Recall, and Review. At risk patient can be identified. At risk patient can be identified. The NPfIT will augment this and The NPfIT will augment this and help the flow of information help the flow of information
DH Chronic Disease Management; the growing problem
27
Other potential tools...
Develop communit y clinical Practice specialist incentives and (nurse led) commissionin teams g
Ensure savings Commissio made in one n care part of the through system clinical benefit all networks involved in chronic care
Integrat e with social care, more intermediate care
Use defined clinical care pathway s
Health care communities and the NHS as whole benefit because investing in chronic disease reaps
health and financial dividends .
The Wanless report, Securing Our Future Health (Interim Report) argued that for every pound invested in self care;
around £1.50 can be reinvested more effectively The economic case for disease management is more complex, but the improvement in quality of life is undeniable. There is a growing evidence base on the possible financial effects of case management (mainly from abroad, but increasingly from the UK). This suggests that investing in primary and community care to support case management will free up scarce acute resources to use more appropriately.
DH Chronic Disease Management; the growing problem 29
The NHS moves from…
doc_906184852.ppt