Aneurin Bevan Health Board Chronic Conditions Management 1 Introduction: This paper presents the Health Board s position in implementing Welsh Government s Chronic Conditions Framework, the Local Delivery Plan and the Service and Commissioning Directives. The paper includes: An overview of Designed to Improve Health and Manage Chronic Conditions. An overview of the Service Development and Commissioning Directives. The implementation of the Health Board s Local Delivery Plan and Service Development and Commissioning Directives. The Board is asked to note the contents of this report. Financial Assessment and link to Financial Recovery Plan Risk Assessment Annual Operating Framework Standards for Health Services Wales Equality Impact Assessment Chronic Conditions Management (CCM) will be managed through core services and through service re-design using existing resources. The Health Board needs to progress the Chronic Conditions Management agenda to ensure appropriate, timely care to patients to reduce reliance on secondary care. Failure to do so will impact on emergency medical admissions and resources. Delivering the CCM agenda will support the Tier 1 priorities relating to Setting the Direction, Unscheduled Care, Stroke, Efficiency and Productivity. The Tier 2 priorities relating to Prevention and Health Promotion, Primary Care, Unscheduled Care, End of Life Care, and Clinical Leadership. The report relates to the following Standards for Health Services - 1, 2, 3, 5, 7, 9, 16, 19, 2 and 23. Considered throughout the work programme. 1
2 Background 2.1 Designed to Improve Health and the Management of Chronic Conditions The Welsh Government set the strategic direction for Chronic Conditions Management in 28 with the publication of Designed to Improve Health and the Management of Chronic Conditions in Wales and its supporting model. It was recognised that there was an over reliance on traditional reactive models of care, which included hospital admissions for acute exacerbations of conditions that could be managed in the community setting. The framework described a model of care, which included self care and focused on managing conditions proactively. The model described a planned and integrated approach, which was based on anticipatory care and evidence based interventions. Welsh Government developed a three year Improvement Plan, which aimed to: Integrate and more effectively plan, manage and, where appropriate, reconfigure existing services and support, to improve service delivery to patients. Improve health and well being and minimise the risks associated with living with a chronic condition, while supporting and empowering people to maximise their independence in all areas of life. Simplify access to services and improve communication between patients and professionals. Reduce levels of morbidity and avoidable emergency admissions to hospital. Redress the balance of service provision across primary, community, social and secondary care. Provide comprehensive, consistent, preventative and anticipatory care. Build on the strengths within primary care to integrate services across organisational boundaries. Help clarify the actions needed to implement the CCM Model and Framework and set out a new vision for CCM services in Wales. 2.2 Service Development and Commissioning Directives for Chronic Respiratory Conditions, Arthritis and Musculoskeletal Conditions, Epilepsy, Diabetes and Chronic Non Malignant Pain The Service Development and Commissioning Directives were developed to give the strategic direction for redesigning the care of chronic conditions in line with the Chronic Conditions Management Model and Framework and the CCM Service Improvement Plan. The Directives set 2
out a range of actions and identified timescales. The Health Board was required to achieve 95% in all four Directives by 31 March 211. 3 Aneurin Bevan Health Board s Local Delivery Plan: To respond to the above, the previous organisations developed a 29 211 Local Delivery Plan for Chronic Conditions Management. This plan included the following: A vision of how chronic conditions management would be improved over the two year period. Alignment to the high level aims of the Chronic Conditions Management Framework and Annual Operating Framework targets for 29/21. The delivery of the national targets for 29/1 and the wider policy requirements to improve chronic conditions services. A single Improvement Plan for the six predecessor organisations. Appendix 1 gives a comparison of QOF Prevalence data between 29/1 and 21/11 3.1 Implementation of the Local Delivery Plan A Chronic Conditions Management Steering Group was formed to develop and implement the Local Delivery Plan and the Service Development and Commissioning Directives. This Group reported to the Primary and Community Care Board and included representation from all Divisions, Locality Chronic Conditions Management Leads, Clinical Directors, Primary Care and Human Resources. The Group also developed sub-groups for Chronic Obstructive Pulmonary Disease, Diabetes, Epilepsy and Case Management. The Case Management Group relates to the proactive management of patients at high risk of hospital admission. This workstream linked with the Unscheduled Care Transformation Board Primary Care workstream to develop a risk stratification tool to retrospectively review and manage patients with high numbers of emergency medical admissions. The aim of which was to decrease the frequency of admissions and deliver more appropriate services to patients and their carers. The risk stratification process has involved: An audit on a 12 month rolling period. Grouping of data into practices in order to follow up in a comprehensive manner. Identification of patients with more than three attendances. 3
Exclusion of those patients with no attendances within six months over a 12 month period. A review of patients every two weeks to discuss progress at Locality level. Allocation of case managers and agreed actions to support these patients. The outcomes of this work to date have been: A standardised process to case management across the Health Board. A process in which to highlight and expedite complex cases. An opportunity for shared learning and support across the Health Board. Improved communication and co-operation between all health and social care professionals. Detailed information on the numbers of patients, their conditions and behaviour for localities, GP Practices and Neighbourhood Care Networks. Improved targeting of resources to patients with the greatest need within the localities. Appendix 2 gives an overview of the audits completed to date. The next step in analysing this data is to look at cross referencing this information with list size and prevalence data to establish any patterns. As more patients are case managed the results of the data analysis will enable a profile of potential key risk areas for admission and attendance. NCN s will need to look at the data around Primary Care referrals to establish actions and work will be required around those patients who attend directly to Accident and Emergency Departments. 4 Current Position: 4.1 Local Delivery Plan Appendix 3 gives the position at March 211 in implementing the Local Delivery Plan. The ongoing actions include: Continue to support the Diabetes Planning and Development Group, Epilepsy and Chronic Obstructive Pulmonary Disease Groups linking with other work programmes, where appropriate such as the Unscheduled Care Transformation Board and Medicines Management Board. Continuing to support the Aneurin Bevan Health Board/Glaxo Smith Kline Primary Care Education Programme. 4
Continue to refine case management and the Health Board approach to frequent fliers, through the Locality Community Flow Groups and Community Resource Teams. This will be expanded to include care homes. Continue to develop clinical leadership through the development of Neighbourhood Care Network Clinical Leads and the wider organisational clinical network. Deliver the High Impact Changes and actions in the 211/12 Annual Quality Framework. Continue to monitor performance relating to chronic conditions management through the performance frameworks for the Neighbourhood Care Networks. 4.2 Service development and Commissioning Directives The graphs below highlight the Health Board s position and its relation to the All Wales Position at the end of March 211. The established groups to implement these Directives are all continuing with their work programmes and are being linked to the Neighbourhood Care Network Clinical Leads to maximise integration across all care settings. All Actions within Service Development Commissioning Directives 1 8 6 4 2 All Wales ABHB Non Complete 75%-94% Completed Complete ( 95% +) Individual Service Development Commisioning Directives End Position March 211 1 8 6 4 2 Arthritis Epilepsy Pain Respiratory All Wales ABHB 5
5 Next Steps: The Chronic Conditions Local Delivery Plan and transitional work programme, supported by Welsh Government, ended in March 211. The High Impact Changes: Delivering High Quality, Cost Effective Care in the Community sets out a framework that will enable the high impact changes to be implemented to support the delivery of high quality care for patients with chronic conditions in the community. This Chronic Conditions Management agenda also continues to be progressed through the implementation of Setting the Direction: The Strategic Delivery Programme for Primary Care and Community Services. This will be monitored through the NHS Wales Delivery Framework for 211/12. Delivering the CCM agenda will support the: Tier 1 priorities relating to Setting the Direction, Unscheduled Care, Stroke, Efficiency and Productivity. Tier 2 priorities relating to Prevention and Health Promotion, Primary Care, Unscheduled Care, End of Life Care, and Clinical Leadership. The work programme for chronic conditions management is currently being reviewed to ensure full integration across the Health Board, reflecting the development of Neighbourhood Care Networks and General Medical Services Quality and Outcomes Framework Quality and Productivity Indicators relating to reducing emergency medical admissions and prescribing. Prepared by: Bobby Bolt, Blaenau Gwent Locality Director Sponsored by: Joanne Absalom, Director of Primary, Community and Mental Health Services Date: September 211 6
Appendix 1 Aneurin Bevan Health Board Comparison of QOF Prevalence 29/1 to 21/11 28. 27. 26. 25. 24. 23. 22. 21. 2. 19. 18. 17. 16. 15. 14. 13. 12. 11. 1. 9. 8. 7. 6. 5. 4. 3. 2. 1.. AF ASTHMA BP CHD CKD COPD DIABETES EPILEPSY HF (1) HF (3) OBESITY SMOKING STROKE 29/1 1.59 6.6 15.73 4.17 3.62 2. 5.4.74.93.48 11.22 26.8 1.94 21/11 1.64 6.65 15.89 4.13 3.66 2.6 5.66.75.93.48 11.51 26.36 1.98 21/11 Actual Numbers of Patients AF ASTHMA BP CHD CKD COPD DIABETES EPILEPSY HF (1) HF (3) OBESITY SMOKING STROKE 9,791 39,595 94,643 24,593 21,817 12,255 33,678 4,473 5,538 2,858 68,566 156,932 11,87 7
Case Management Frequent Fliers Audits 1 & 2 (25 patients per cohort) Appendix 2 Audit 1 collated information on the first 5 patients with multiple admissions or attendances that were case managed from each Locality. Audit 2 collated information from a further 5 patients in each Locality ( Newport collated 24 patients) This gave a total of 474 patients to analyse trends and progress to date. Results Case Management Status- First Audit 4 35 3 25 2 15 1 5 Green Amber Red Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen Case Management Status- Second Audit 35 3 25 2 15 1 5 Green Amber Red Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen 8
Case Management Status- Total 7 6 5 4 3 2 1 Green Amber Red Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen The first audit shows the status of the first 25 patients that have been case managed using the Frequent Fliers criteria. A green status shows that since intervention there have been no further admissions or attendances for a full 6 months, Amber shows no further admissions/attendances since intervention. At the time of the audit these patients have not yet reached the full 6 months but are over a month. Red shows patients who have continued to present despite intervention. Due to the fact that Amber status is a positive result and patients can remain in Amber status at 5 months and 3 weeks, it is helpful to also view these patients in terms of a positive outcome to intervention and no change following intervention. Overall Outcome since Intervention- First Audit 5 4 3 2 1 Positive No Change Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen 9
Overall Outcome Since Intervention- Second Audit 5 4 3 2 1 Positive No Change Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen Overall Outcome- Total 1 8 Blaenau Gwent 6 Caerphilly 4 2 Monmouthshire Newport Torfaen Positive No Change These results highlight more clearly the positive effect of case management on the cohort of frequent flier patients. Newport s results in the second audit and therefore total outcome are not as clear due to a smaller number of patients included in their audit. Those patients within the positive results are actual reductions in admissions and attendances. It should be noted that these indicate each patient and these patients have had an average of 5.4 attendances each in a 12 month period prior to intervention. 1
Morbidities -Total 1 8 Blaenau Gwent 6 Caerphilly 4 2 Monmouthshire Newport Torfaen single Total 2+ Total The table above highlights the breakdown of morbidities in each Locality. It highlights that of those 1 patients in Blaenau Gwent, 94 % have co morbidities. Caerphilly also has high numbers of patients with co-morbidities. These patients are highly complex and therefore benefit from the focused case management strategy of the frequent fliers work stream. Route of Attendance-First Audit 35 3 25 2 15 1 5 A&E GP OOH TRANSFERS OTHER Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen The table above highlights the route that these patients took in their attendances. This shows that the predominant route taken was via A&E. It is not possible at this stage to determine if this is via direct access to A&E or via WAST. 11
Ages- Total 4 35 3 25 2 15 1 5 Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen -19 2-3 31-4 41-5 51-6 61-7 71-8 81-9 91-1 1+ The table above highlights the age groups of the cohort of patients. The largest age groups in general are 7-9. 12
Wednesday 28 APPENDIX September 211 3 Aneurin Bevan Health Board Final Chronic Conditions Local Delivery Plan Matrix Objective Action Delivered 1. Complete service mapping for all 5 LHB areas using template developed by NLIAH 2.Refine the baseline position across all four levels of the Welsh Chronic Conditions Model 3. Agree process for engagement with all professional groups and clinical teams Establish CCM Sub groups for Respiratory, Diabetes, Cardiac, Stoke and Case Management Identify patient need and gaps in service to Map capacity across Gwent. Monitor CCM data (QOF / NPHS). Identify mechanisms to capture activity information across the 4 levels of the CCM Model. Monitor the Activity information across the 4 levels of the CCM Model. Monitor CCM Activity against the Service Improvement Maturity Matrix Clinical Leads Identified for all major groups. Clinical Leads to be members of the Gwent CCM Group. Groups will meet on a monthly basis and report via the CCM Steering Group. Undertake a training needs analysis for staff delivering CCM services. Establish a training programme, based on need, for relevant clinicians and managers regarding the new models of Completed 29 Completed March 211 Mechanism in place to monitor CCM activity across the 4 levels of the CCM Model. CCM information informs impact of service developments. Baseline position is completed and now is used effectively to monitor and inform.e.g.; CCM Activity information is utilised for case management and frequent fliers management. Completed October 21 The case management group has fed into the district nursing strategy and frailty work stream in order to highlight training needs for core staff.( tier 3 & 4) The diabetes professional education forum is in place The epilepsy sub group has established a mentoring system where by GP s and other clinical staff can shadow Consultant or specialist nurse clinics. Next Steps / Links with other work streams To continue within Case management, frequent fliers and Primary Care Performance work streams Diabetes Planning and Development Group and supporting sub groups, Epilepsy and Respiratory/COPD Group will require support following March 211. The COPD education project requires continued support 211/212 GSK/ABHB Education programme 13
CCM care. A COPD Project has been established in collaboration with GSK to provide education within Primary Care. 4. Ensure Service Development Groups in place. Agree Terms of reference and reporting mechanisms for all groups. Clear reporting arrangements, membership and group objectives in place. Recruit to CCM Service Improvement Managers and Facilitators Posts. Completed December 21 Groups established by December 21 and report into the CCM Steering Group Monthly. Team recruited on a secondment basis December 21-March 211 See 3 5.Develop role profiles for GP Clinical Champions 6.Develop demand and capacity plan, informed by the above, identifying key areas for improvement Recruit Clinical Champions for Respiratory Cardiac, Diabetes, Stroke, NMCP, Renal and Care Co-ordination Using NLIAH Service Mapping tool, identify capacity across Gwent in the 4 areas of the CCM Model. Map against Projected Need Completed 29. High Level Capacity work Completed Development of GP Lead roles within NCN s will need to focus on delivering the High Impact Changes and AQF. GSK, COPD education project will need to continue to be supported Future work on capacity and demand will focus around the delivery of the AQF, High Impact Changes Action Plan and as part of the 5 year plan. 7.Develop Performance Management Framework to monitor the impact of developments on overall team and organisational performance linking with Develop Activity Monitoring Reports Identify and agree Key Indicators to monitor service improvements. Monitor WAG / Organisational Targets Identify and agree 4 Site Specific The CCM steering Group has managed performance via Service Commissioning Directives, Diabetes NSF, and EMA S, LOS and other Primary Care and frequent flier data have also been developed into a performance dashboard. Performance management established and will continue to be monitored. AQF and the High Impact Changes Delivery Plan will 14
Health Care Standards and 1 Lives Campaign. performance indicators Service Commissioning Directives (respiratory, epilepsy, MSK and Chronic non malignant pain) have met the WAG target for over 95% compliance. need to have accompanying actions developed, monitored and reported. NSF Diabetes action plan will continue to need developing and monitoring. Frequent flier work stream will need to continue. 8.Develop financial frameworks to monitor the impact of developments on overall team and organisational performance 9.Agree model for case management and implement across Gwent Identify the baseline financial positions across the 4 levels Develop systems to monitor the impact of the CCM Model implementation on acute services and reduction in the number of Emergency Medical Admissions. Identify current services in place across Gwent. Site specific teams to agree principles for case management and Clinical Governance framework. Implement model across Gwent See performance developments above. The impact of the CCM model on acute services will be measured via these performance measures. The model has been agreed and needs within each Locality identified. Core competencies for level 3 and 4 have been identified and with HR involvement have fed into the district nursing strategy and frailty work streams. Tier 1 core competencies are being identified by public health. The model of case management has been joined to the frequent fliers work stream in This work will need to be linked to NCN s as part of their performance framework This work will need to continue linking performance with, finance, case management and frequent flier work streams. This work will need to be linked to NCN s as part of their performance framework Locality Community flow groups and case management group will need to continue until fully established NCN s can oversee the frequent flier agenda. NCN s will need to look at engagement across Primary Care in establishing core case management skill and competencies for practice nurses.9 level 2) 15
order for effective working and to avoid duplication. Links with Care homes will need to be progressed. Pilot to be carried out within Blaenau Gwent Locality. 1.Implement PRISM/Population risk stratification tool in all General Practices Develop a plan to implement PRISM / Risk Stratification Tool in all practices. Develop and agree LES for Risk Stratification, including the introduction of Audit+ software in all Practices. PRISM has not been rolled out on an all Wales basis due to issues identified as part of the CCM Demonstrator programme. ABHB has implemented a retrospective risk tool to manage frequent fliers. Case management needs to be continued to be supported and developed as part of the High Impact Changes. See 9 Predictive risk tools need to be implemented once PRISM is available or alternative method identified. Locality groups are feeding into the case management sub group of the CCM Steering group fortnightly. This reports via the CCM Steering Group and Unscheduled Care Board.( Commenced March 211) WAST- need to establish links and protocols and share risk stratification tools Mental Health risk stratification work to date has highlighted this as an area that is impacting on frequent admissions. E.g. 1 practice had 95 admissions over a 12 month period from 7 patients. 16
11.Develop process for care co-ordination of those patients identified at being at risk admission Agree Job Descriptions and Preliminary Operational Policy for Care Coordination to include Clinical Governance framework. Recruit to Posts Agree Networked Cluster Groups across Gwent, identifying key Clinical leads. Separate and new roles have not been developed due to financial and resource implications and the strategic direction to integrate as part of core services across the organisation. The case management group has developed core competencies and skills (linking in with frailty, Public health. district nursing strategy) Care Homes and Primary Care Nursing roles will also need to be developed in respect of core competencies required to case manage CCM patients. This will be integral to the work of the NCN s 12.Implement the care pathway for Chronic Obstructive Pulmonary Disease 13.Agree plan for care pathway developments for other diseases 14.Develop plans to support core services through engagement, education and training throughout 29/211 to support service change and ensure sustainability of case management and care coordination Monitor clinical, organisational and patient identified outcomes (to be agreed at COPD Workshop in March 29). Identify any potential impact on the current workforce addressing and education, role redesign and reconfiguration issues to include Clinical Governance Framework. Agree programme of Care Pathway development based upon Map of Medicine, linked to IHC and NLIAH CCM work stream. Evaluate process used to develop COPD Pathway. Identify Core Services involved in CCM Ensure appropriate representation on all site specific and care coordination groups. Further development work has been undertaken between December 21 and February 211. This has led to the submission of the completed Pathway for launch and publication on Map of Medicine. Completed February 211. Pathway development taken place around Generic Chronic Conditions, TIA, Stroke and cardiac. National Decision that Map of Medicine will not continue after March 21 Appropriate representation has been involved to ensure sustainability of case management into core services. The Case Management sub group has looked at core competencies and training needs across the 4 tiers of CCM. See 9 and 1 17
18