Integrating Community and Primary Care: the eyes and ears of general practice

Transcription

1 re Integrating Community and Primary Care: the eyes and ears of general practice

2 Context and Evidence Increasing numbers of people over 65 with chronic conditions being managed in primary care. Acute exacerbations of COPD and CHF in people over 65 are leading causes of avoidable hospital admissions. The earlier an exacerbation is identified, the less likely an associated hospital admission and the smaller any associated loss of function. (Lynn and Adamson 2003)

3 Context and Evidence Long-term community support care Exacerbations Entry to residential care Aim to lengthen this period

4 Project development timeline March 2015 NM approves June August Detailed project planning. Partnership with 4 practices April May External stakeholder consultation Late August Start 6 month trial with 8 clients.

5 Development Projects Risk Management 1 Concept Approval: idea worth exploring? 2 Feasibility Trial: Will it work in practice? Get processes right 3 Full trial: Prove cost/benefit 4 ROLL OUT

6 AIMS Identify shared NM homecare and GP clients with COPD and CHF Routine symptom survey at existing scheduled visits Test a prototype service model to see if it could: Improve health outcomes (reduced hospital admissions, reduced acute hospital bed stay days) Improve primary care/nurse Maude communication Any and relationships concerns generally, thereby improving care coordination faxed for all to shared clients practice Improve patients experience of co-ordination of care Improve general practices confidence to manage complex clients within the community Exacerbations identified earlier enabling primary care management And to identify best processes and true costs

7 Identify shared NM homecare and GP clients with COPD and CHF Routine symptom survey at existing scheduled visits All symptoms and weight info faxed to practice Exacerbations identified earlier enabling primary care management

8 Types of alerts A chance to educate about why CHF COPD weight Total is SMQ delivered 155 Total SMQ delivered 129 Critical important. signs # Occasions Alert 13 # Occasions Alert 17 Start short Agree that and course medications Not taken medication as document a 0 Shortness of breath antibiotics? 6 controlling directed baseline. fluid retention Not might weighing per plan 3 Sputum change 10 need adjusting Weight increase >2kg Chest tighter or 4 baseline wheezier 9 Swollen legs 5 Coughing more 15 Shortness of breath 4 Cold symptoms 2 Combined Triggers/Issues 16 Combined Triggers/Issues 42 Incl Weight 3 Incl Weight 1 Weight only Weight only 25

9 Client No. CHF or COPD TOTAL All Length SMQ Confirme Practic All of time Hospital Hospital generat d FAXED e Practice % Client CHF This or is the # extra on the Visits 6 Visits Age ing Alerts / Contact Contact Chan 3 No. COPD SMQs 74 service Alerts/ 29 6 months During weight 6 During ge 286% 0 amount of (weeks) prior Service Weight data months Service * data prior 1 CHF % CHF % COPD % COPD % % CHF % -1 6 COPD ^ 25^ % 0 0 we did in the 8 7 COPD CHF % 200% home 8 COPD % % 122% Total (avg) Age # SMQs delivered Confirmed FAXED Alerts / weight data % Change in general Practice by 22% contact (mainly PN phone) (avg) +/-Hosp admissions 1 CHF % -3 2 CHF % -1 4 COPD % 0 5 CHF % 3 6 COPD ^ 125% 0 This is the extra Total communication to practices (avg) It increased Gen Practice contact with clients a lot (mainly nurse phone calls) It decreased Acute Hospital admissions (avg) -2

10 Alerts triggered, contact with GP or Practice Nurse April 15- March 16 First 6 clients 7 clients 8 clients PN contacts increase 1 st ; then GP contacts Both drop off after a while Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2016 Jan2016 Feb 2016 Mar Practice Contact- GP Practice Contact- Nurse Alert Triggered

11 SW feels great Client feels safe hasn t had any admissions since being on the service GP confident Case-Study 76, lives alone, advanced COPD. Mulitple daily visits. SMQ scheduled 1xper week 2pm. SW reports Increased shortness of breath, coughing, Sputum change GP visit. Revise all medications. GP confident to continue at home due to monitoring 2.35 Practice Faxed 3pm Fax given to GP to review. Next week: SW identifies no improvement. New FAX Following day: PN contact check progress. Book GP for after standby meds. 4pm PN contacts client. Starts standby medications. GP requested PN phone contact

12 Interim evaluation conclusions: Very encouraging about the potential value of the project. Definitely working to Foster positive engagement between primary care and Nurse Maude Stimulate health conscious behaviour in support workers and clients Routinely collect and transmit highly relevant data about clients clinical condition. Stimulate greater pro-active contact with clients from the general practice team. However: Manual nature of the processes supporting the project need automating in order to be sustainable and minimise any client risks.

13 Full trial at scale. Requires at least 6 months data for over 200 clients to be conclusive AIM Prove that this model is effective for avoiding admissions and delaying entry to residential Provide a detailed cost / benefit analysis. WATCH THIS SPACE.