Herefordshire Clinical Commissioning Group Long Term Conditions Strategy & Implementation Plan 2013-2016 1
Contents Definition.3 Background.3 Framework for Long Term Conditions 4 Chronic disease management diagram.. 5 The Strategy for Long Term Conditions in Herefordshire....6 Implementation Plan..7 Measurement of Outcome 10 References and Supporting Documents Appendix 2
Definition A Long Term Condition (LTC) is defined as a condition that cannot, at present be cured but is controlled by medication and or other treatment/therapies. Department of Health (DoH) (2012) The World Health Organisation (WHO accessed 2013) also adds that it limits what one can do. Background Skills for Health (2013) note that 60% people in Britain have at least one LTC. It also notes that over 66% of admissions and 80% primary care consultations are related to LTCs. This equates to 109,800 people with at least one LTC within the 183,000 population of Herefordshire. Appleby (2013) states spending on long-term care in 2061 could range from 1.5 per cent to 2.5 per cent of the gross domestic product (GDP) compared with 1.1 per cent in 2016, increasing per capita spending by more than fivefold from 276 to 1,491 on the higher projection. In addition to this people over the age of 75 are more likely to be readmitted in comparison to those under 75 and are more likely to remain in hospital 14 days longer. The DoH (2012) cite the General Lifestyle Survey (2009) which states that around 70% of the total health and care spend in England ( 7 out of every 10) is attributed to caring for people with LTCs. This means that 30% of the population account for 70% of the spend. The prevalence of many LTCs in Herefordshire are high compared to comparator PCTs and to England, and are predicted to rise over coming years. The prevalence of: o Diabetes is estimated at 8.1% compared to 7.7% in comparator PCTs o CHD is estimated at 6.7% compared to 6.3% in comparator PCTs o Stroke is estimated at 2.9% compared with 2.8% in comparator PCTs o COPD is estimated at 3.5% compared with 3.2% in comparator PCTs. (Herefordshire Gov. 2013) The fiscal data and prevalence figures demonstrate the need for an evidence based strategy to support Herefordshire to address the needs of the population with a LTC to maintain and improve quality of care for this cohort. 3
The Department of Health (DOH 2013) will not be producing a LTCs strategy as planned however advocate Support to develop the skills for self care and to become experts in their own health A personalised care plan (management plan) if they want one Better co-ordinated care based on what each person wants Framework for Long Term Conditions The Herefordshire Clinical Commissioning Group (HCCG) Strategy enables flexibility as evidence based medicine evolves, technology develops and people choice alters in response to their knowledge and external influences e.g. media, personal beliefs and experiences. The Kaiser Permanente chronic disease management pyramid (Fig.1.) conceptualises risk stratified groups of peoples with LTCs. The aim is for the majority of people with a LTC to fall within level 1 requiring minimal professional intervention and managing their LTC on a basic level- supported selfcare. Level 2 requires proactive care and specialist intervention utilising information systems, shared electronic records and care/management plans- high risk patients. Level 3 is for people with complex LTC needs requiring case management and a key worker to coordinate their care needs. The pyramid summarises the approach to managing LTCs in its simplest form (Scotland.Gov 2009). Underpinning the pyramid is making every contact count (MECC). MECC is about using every opportunity to talk to all individuals, whether they have a LTC or not, about improving their health and well being.the strategy itself provides more depth to the underpinning practices to facilitate this concept of the Kaiser Permanente chronic disease management pyramid and other similar frameworks. 4
The Kaiser Permanente pyramid conceptualises risk stratified groups of peoples with LTCs. Risk Stratification Case Management by Community Matrons/ Rehabilitation / End of Life care Proactive Care Specialist Nurse input District Nursing Care Plan Risk Assessment & Treatment Annual Review Self Care Information MECC* Fig.1 (DoH accessed 2013) *MECC Make every contact count 5
The Strategy for LTCs in Herefordshire Aim The aim of the strategy is to improve health outcomes and wellbeing and to reduce disease progression in all LTCs in Herefordshire. The strategy is overarching and will not focus on specific conditions. It will provide a generic framework for all LTCs and enable relevant local groups/service providers to develop action and implementation plans necessary to realise improvement in Herefordshire Objectives To Improve supported self care Reduce unscheduled admissions and readmissions Maintain and improve quality of care Reduce health care costs Outcomes To: Facilitate supported self care Improve people education and knowledge of LTCs Further embed and further develop all existing programmes Enable services to be delivered closer to home Reduce the number of admissions and length of stay for those with LTCs Up-skill the integrated workforce-primary care and neighbourhood teams in managing LTCs Improve quality of life and care experience for service users and carers Embed service user involvement Integrate pathways through Map of Medicine Utilise evidence based technology to support those who care for and those with LTCs where appropriate 6
Implementation Plan In order to support people with LTCs at all levels and to prevent them moving up a level, especially those with complex needs, support from a number of different professionals and agencies may be needed. By integrating multidisciplinary teams and agencies seamless care can be initiated and confusion and duplication of effort avoided. A proactive rather than a reactive approach to case managing those with LTCs can prevent unnecessary admissions to hospital or reduce any unnecessary length of stay if they are admitted. In order to meet the aims and objectives of this strategy HCCG advocate the implementation of the following. 1. Management plans/personalised care plans, Anticipatory Care Plans, discharge pro-formas collectively called Collaborative care planning Rationale: To enable patients, carers and care providers initiate and deliver ongoing integrated care for people with a long term condition. The plans are developed with the patients and therefore empower them to have the care they want and need. A collaborative care plan prompts shared understanding and decisions about choice; improves concordance and patient access. Each person with one or more LTC should know their key contact(s) and how to access advice including outside normal office hours. Management plans are developed with the patients and healthcare provider to provide a mutually agreed plan of care for ongoing and exacerbation management of a LTC. In contrast anticipatory care plans are again developed with the patients, carer and care providers with specific directives to avoid unnecessary hospital admissions and to ensure people receive care in a place of their choice including end of life care. This is particularly useful for paramedics and professionals who have not previously been involved in the person s care before. This should prevent people dying in hospital if this is their wish. Discharge pro-formas are written when a person with a LTC is discharged from ongoing follow up within a specialty. It may include medication, outcome measures and preferences on discharge; recommendations for investigations and treatment if there is an exacerbation of that condition and directions for appropriate re-referral for to the specialty 7
2. Supported Self care (SSC) Rationale: To facilitate self efficacy, integration of management, anticipatory plans and discharge pro-formas. Evidence shows that proactively managing a LTC is better than reacting to it. By creating an environment where people feel supported and encouraged they can manage their LTC with minimal intervention. HCCG will 1.develop and support SSC by sharing best practice across professional networks in primary care and across the primary secondary care interface including specialist nurses. 2. Identify appropriate healthcare technology and support its implementation to facilitate SSC 3. Map of medicine Rationale: To ensure integrated equitable and evidence based practice by providing care providers with standardised evidence based pathways. Map of Medicine enables access to national and locally agreed pathways developed in collaboration with key specialties and people engagement. Map of medicine will enable key elements of the strategy to be put into practice in Herefordshire and improve health outcomes and prevent unnecessary interventions. 4. Educate health care professionals and assistants in the management of LTCs Rationale: To enable access to evidence based care across primary and secondary care. HCCG will encourage education and networking within primary and secondary care. This will also improve communication across care providers and enable carers to interact more readily regarding patient issues. The appendix demonstrates a piece of work initiated to educate and facilitate networking across primary and secondary care. 5. Patient Education in LTC Rationale: Facilitate self efficacy, integration of management plans. Patients can be supported to self-care through developing networks and delivery of appropriate information, interventions and technology, to give patients the opportunity to improve their quality of life, and feel that they are still contributing in their community. Patient education is essential to facilitate better self-management. 8
6. Risk stratification and Risk Profiling Rationale: To identify people with a LTC, individuals or groups of individuals that are most at risk of deterioration in their health and well-being which may result in an unplanned admission to hospital. It could also be used as a predictor for intensive social care. By identifying people at increased risk pre-emptive action can be taken and resources targeted to greatest effect, thereby reducing the risk of hospital admission and maintaining independence for as long as possible. Used with appropriate interventions it has the potential to: improve clinical outcomes, reduce use of both primary and secondary healthcare services and reduce healthcare costs 7. Incorporate local and national charitable resources to improve well being Rationale: Many of these services are free and may provide cost effective ways of maintaining or improving physical and mental well being. The Herefordshire CCG will encourage the integration of such organisations into the management of LTCs either via specialist provider services or directly from the charitable organisation. These organisations will be encouraged to make contact with HCCG. 8. Incorporate evidence based/cost effective technology Rationale: There is potential to reduce death rates, hospital admissions and visits to Accident and emergency with the correct use of telehealth and telemedicine. HCCG will explore and research the evidence for implementation of this technology locally, review and implement if financially viable where its use has been demonstrated as improving health outcomes or where a pilot of this has been deemed appropriate. 9. Electronic (e) consultation Rationale: To provide primary care with timely specialist opinion on managing complicated patient issues which may not warrant an outpatient consultation but does require more specialised advice. The e-consultation pathway involves identifying specialties where consultants feel patients could be managed virtually if relevant clinical information were provided. Feedback from The Suffolk project called Advice Letter Listing scheme (ALL) suggested that it provided specialist opinion and management plan within a week, reduced referrals in some specialties and ensured the peoples had all the relevant tests and trials of care before being seen by the consultant 9
Measurement of outcome The success of this strategy will be measured by Implementation of risk profiling, collaborative care planning and integrated care teams. Patients and carers experience of appropriate and rapid access to high quality services: the right place at the earliest time (applies across primary, secondary and social care, as well as preventative services) Patients and carers belief in SSC Reductions in admissions, re-admissions and length of stay for people with a LTC Patient s experience an integrated approach to their care, across primary, secondary and social care services e.g. use of management plans across both care teams Evidence that people are supported to stay out of hospital where practicably possible through interventions and documentation Implementation of Map of Medicine and e-consultation 10
References and Supporting Documents Alcohol Harm Reduction for England in 2004. Cabinet Office Combined Predictive Model Final Report: Health Dialog/King s Fund/New York University; 2006 Appleby John (2013) Spending on health and social care over the next 50 years Why think long term? Kings Fund (2013) http://www.kingsfund.org.uk/publications/ Cornwell J, Levenson R, Sonola L, Poteliakhoff E. (2012)Continuity of care for older hospital peoples: A call for action. Kings Fund http://www.kingsfund.org.uk/publications Department of Health(DoH) (2012) LTCs Compendium DoH London Common core principles to support self-care: A guide to implementation, Skills for Health 2008. Department of Health (2005) Supporting People with LTCs, An NHS and Social Care Model to support local innovation and integration. DH 2005 Department of Health (2007)National Stroke Strategy, DH Dec 2007 Department of Health (2007)Self Care: A National View in 2007 Compared to 2004-05. DH June 2007 Department of Health (2007)World class commissioning: Competencies, DH December 07 Department of Health (2008)World class commissioning: Commissioning Assurance Handbook, DH Jan 08 Department of Health(2008) The National Service Framework for Long-term Neurological Conditions National Support for Local Implementation, DH 2008 Department of Health (2008)Raising the Profile of LTCs: A Compendium of Information. DH Jan 2008 Department of Health (2008) http://learning.nhslocal.nhs.uk/courses/areas-care/health-managementresources/making-every-contact-count Department of Health (2008)The National Service Framework for Long-term Conditions, DH March 2008 Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report, DH 2008 Department of Health (2008)Transition: Moving on well. A good practice guide for health professionals and their partners for young people with complex health needs or a disability. DH Feb 2008 Department of Health (2013) http://longtermconditions.dh.gov.uk/ Department of Health Modernisation agency accessed 2013 http://www.natpact.info/uploads/pyramid%20- %20Chronic%20Disease%20Management.pdf Department of Health Disease Management Information Toolkit: http://www.dh.gov.uk/en/healthcare/longtermconditions/dh_074772 Herefordshire.gov.uk (2013) http://factsandfigures.herefordshire.gov.uk/ 2013 Gov.uk (2013) https://www.gov.uk/government/policies/improving-quality-of-life-for-people-with-long-term-conditions Kaiser Permanante: Supporting People with LTCs. An NHS and Social Care Model to support local innovation and integration, DH 2005 Kings Fund (2013) http://www.kingsfund.org.uk/publications Modernisation Agency http://www.natpact.info/uploads/pyramid%20-%20chronic%20disease%20management.pdf accessed February 2013 Kings Fund. Ten Priorities for Commissioners (2013) http://www.kingsfund.org.uk/topics/commissioning/commissioningresources?gclid=cmybu4xi0bucfczhtaodj2yaaq Managing LTCs to reduce unplanned hospital admissions and improve care of Hartlepool peoples, Jan 2005 Momentum Pathways to Healthcare LTCs Project Report, April 2008 Momentum Pathways to Healthcare Step Up/Step Down Project Report, April 2008 Our health, our care, our say: a new direction for community services, DH Jan 2006 11
Our vision, our future. Our North East NHS. A strategic vision for transforming health and healthcare services within the North East of England. May 2008 Our NHS, Our Future. Darzi NHS Next Stage Review, NHS North East LTC Clinical Working Group. Draft Report Feb 08 Pharmacy in England: Building on strengths delivering the future April 2008 Putting People First A shared vision and commitment to the transformation of Adult Social Care, Dec 2007 Scottish Government Health Delivery Directorate Improvement and Support Team Long Term Conditions Collaborative Improving Care Pathways (accessed April 2013) http://www.scotland.gov.uk/publications/2009/12/03112054/4 (2009)(accessed 2013) Sensible, Safe, Social, The next steps in the Alcohol Strategy. Cabinet Office 2007 Skills for health (2013) http://www.skillsforhealth.org.uk/service-area/long-term-conditions/ accessed February 2013 Working for a healthier tomorrow Dame Carol Black s review of the health of Britain s working age population. 17 March 2008, London TSO World health Organisation (WHO) (2013) http://www.who.int/en/ accessed 2013 World class commissioning: Competencies, DH December 07 World class commissioning: Commissioning Assurance Handbook, DH Jan 08 12
Appendix Subject: Presented By: HEREFORDSHIRE CLINICAL COMMISSIONING GROUP Service Transformation & Innovation Group Date: Improving health outcomes and quality of life for patients with long term conditions by involving primary care nurses Cate Lamport PURPOSE OF THE REPORT: To update STIG on the development work being undertaken to inform the Long Term Condition Strategy which will be discussed at STIG by May this year.. KEY POINTS: Establish an active primary nurse group to improve care of patients with long term conditions, and provide seamless care between primary and secondary care. RECOMMENDATION TO THE COMMITTEE: To note the setting up of the primary nurse group as an important stage in the development of the long term conditions strategy. CONTEXT & IMPLICATIONS: Financial Legal Risk and Assurance (Risk Register/BAF) HR/Personnel Equality & Diversity N/A N/A N/A N/A Open to all Primary care Nurses in Herefordshire Strategic Objectives Healthcare/National Policy (e.g. CQC/Annual Health Check) Partners/Other Directorates Carbon Impact/Sustainability Other Significant Issues To improve health outcomes and quality of life for patients with long term conditions NICE Guidance DoH 2012 Long term conditions Compendium COST N/A N/A GOVERNANCE Process/Committee approval with date(s) (as appropriate) 13
HCCG Primary Care Practice Nurse Education Programme Project Plan March 2013 This project plan forms a key strand of the Long term Conditions Strategy. It is presented separately as there are particular organisational and developmental issues. Aims To implement the Long Term Conditions strategy within primary care, through an educational programme for practice nurses To improve health outcomes and quality of life for patients with Long Term Conditions in Herefordshire. Objectives To develop an educational programme for primary care practice nurses in Herefordshire that: Focuses on management of long-term conditions Facilitates the introduction of supported self-care, so that patients can set their treatment goals Empowers patients to self-manage their long term conditions, through management plans and education. Plan Form a virtual e-mail primary care practice nurse liaison group Set up a regular e-mail blog to allow concerns, good practice, protocols, dissemination of evidence based guidelines and innovative ways of working to be shared. Initially focus on COPD, heart failure, diabetes and chronic neurological conditions. Establish an active Primary Care Practice Nurse Education Group Identify current educational needs of the Group through a survey Plan a programme of quarterly education events that: o Address the identified education needs o Address management of long term conditions for primary care nurses o Support supported care and patient education/self-management o Integrate with local secondary care specialists, locally agreed care pathways, and locally agreed self-management plans Plan group nurse education with practice managers to share costs and deliver high quality education to meet mandatory training requirements and continue to develop primary nursing skills. Outcomes Outcome based measures are those encapsulated within the Long term Conditions Strategy A number of process issues are listed here: 1. Establishment of Interactive Primary Care Practice Nurse virtual group. 2. Quarterly Primary Care Nurse Educational programme 3. Implementation of evidence based care for Long term Conditions by practice nurses 4. Use of self-management plans within primary care that link in with specialist services 5. Introduction of supported self-management in Long term Conditions Cate Lamport, Practice Nurse Lead for HCCG 14