Managing Long-term conditions and Chronic Illness in Primary Care A guide to good practice (2nd ed.) Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 Aim To discuss effective management of long-term conditions and the importance of systematic and evidence-based care in primary care which takes account of the expert patient. Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 The book Social and political background Physical, psychological and psychosocial impact of living with an LTC and social influences on health Case management and disease-specific care management Importance of self-management Health behaviour change and motivational interviewing How to identify a person with a LTC Effective management of people with a LTC Evidence-based practice Case scenarios Nutritional and medication management Afterword (N.B. All author royalties donated to Bwindi Community Hospital, Uganda and the Gorilla Organisation) Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 So what’s the problem? Increasing numbers/stretched resources Victims of our own success (increased life expectancy has resulted in LTCs emerging as the dominant challenge to health and care systems) Numbers continue to rise due to an ageing population and certain lifestyle choices that people make. Geographical variation (nationally and internationally) Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 So what’s the problem? Patient surveys persistently show that half of patients feel they aren’t involved in decisions about their care (Eaton 2012) Living with an LTC can have a physical, psychological and psychosocial impact on individuals. Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 What systems are in place to help? Service frameworks Local and national policy drivers (e.g. NHS Outcomes Framework and the House of Care Model) GMS contract and QOF Health informatics and Telehealth International/national models of care/service delivery models e.g. Chronic Care Model (Wagner 1998, 2011) Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 Key principles Organisation, culture and mechanisms of delivery Empowerment and person centred care Working in partnership Mobilising community resources Preventative policies Dr Judith Carrier Cardiff University 2015

House of Care Model (NHS England 2014) Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 So what can we do? Assess what level of care is required Provide structured care that is pro-active, holistic and preventative Utilise multi-disciplinary teams effectively Dr Judith Carrier Cardiff University 2015

Assessing the level of care required (Kaiser Pyramid) Dr Judith Carrier Cardiff University 2015

Assessing the level of care required Supported self-care: Collaboratively helping individuals and their carers to develop the knowledge, skills and confidence to care for themselves and their condition effectively. Disease specific care management Case management (DH 2005) Dr Judith Carrier Cardiff University 2015

Supported self-care-what should we be doing in primary care? Implementation gap between policy aspirations and delivery of self-management support in primary care Self-management hindered by: Task driven nature of nurses’ routines Lack of motivation by nurses to engage with self management activities (Kennedy et al 2013) Dr Judith Carrier Cardiff University 2015

Three themes that shape peoples’ responses to self-management The different ways in which people receive their diagnosis The fact that different people have different responses The fact that peoples’ ability to self-manage changes over time (Corben and Rosen 2005) Dr Judith Carrier Cardiff University 2015

Supporting self-management effectively-three themes Good relationships between health professionals and patients The need for patients to have clear information about their condition and guidance on how to access it The need for flexibility in service provision (Corben and Rosen 2005) Dr Judith Carrier Cardiff University 2015

Self-care interventions-what’s effective? All round interventions that include continuing education, physician feedback and patient oriented interventions (Renders et al 2011) Problem-solving interventions (Fitzpatrick et al 2012) Action plans as part of a multi-faceted self management programme (Walters et al 2010) Group education or individual education combined with other self-management strategies (de Silva 2011) Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 Self-care interventions-what’s effective? Patent practitioner encounter should encompass: Sound information at diagnosis Comprehensive, paced, user friendly information Allowing patients to discuss their own ideas about self-care actions, including life-style management Allowing patients to feel listened too and have time to ask questions Time, resources, open access, seeing the same doctor, appropriate referral Orientating consultations towards skills and competencies needed for self care Goal setting and care planning (Rees and Williams 2009) Dr Judith Carrier Cardiff University 2015

Seven characteristics of a ‘good’ self manager The capacity of an individual to: Have knowledge of their condition Follow a treatment plan agreed with their health professional Actively share in decision making with health professionals Monitor and manage signs and symptoms of their condition Manage the impact of the condition on their physical, emotional and social life Adopt lifestyles that promote health Have confidence, access and the ability to use support services (Flinders University 2014) Dr Judith Carrier Cardiff University 2015

Disease specific care management Providing people who have complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and disease-specific protocols and pathways (DH 2005) Dr Judith Carrier Cardiff University 2015

Systematic care approaches The 3 Rs-registration/recall/review Develop evidence-based care pathways and protocols that incorporate teamwork and clear referral criteria Monitor and evaluate service provision using clinical audit and/or quality improvement processes Use telehealth and telecare Dr Judith Carrier Cardiff University 2015

Steps to implement case management Requires the identification of the very high intensity users of unplanned secondary care. Care for these patients is to be managed using a community matron or other professional using a case management approach, to anticipate, co-ordinate and join up health and social care. (DH 2005) Dr Judith Carrier Cardiff University 2015

Steps to implement case management Identify vulnerable patients (agree on criteria) Develop the case manager role Carry out thorough assessments-care planning Co-ordinate care and services Dr Judith Carrier Cardiff University 2015

Utilise multi-disciplinary teams in primary care Effective teams: Include the patient, carer or representative as an essential member of the PHC team. Have a common agreed purpose Agree set objectives and monitor and publicise progress Understand role boundaries Acknowledge skills of others Communicate effectively Select a leader for leadership skills Promote teamwork initiatives and evidence based practice (adapted from Royal Pharmaceutical society/BMA 2000) Dr Judith Carrier Cardiff University 2015

Work closely together-you can’t do this on your own! Dr Judith Carrier Cardiff University 2015

Drawing on evidence to support practice-some resources TRIP database- https://www.tripdatabase.com/ NICE-Clinical Knowledge Summaries- http://cks.nice.org.uk/ NICE guidelines- http://www.nice.org.uk/guidance/conditions-and-diseases SIGN- http://www.sign.ac.uk/ Clinical Evidence- http://clinicalevidence.bmj.com/x/index.html Cochrane Collaboration- http://www.cochranelibrary.com/ Campbell Collaboration- http://www.campbellcollaboration.org/ Joanna Briggs Institute- http://joannabriggs.org/ University of York Centre for Reviews and Dissemination- https://www.york.ac.uk/crd/ Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 And finally Remember that you are not alone, healthcare involves teamwork Respect the knowledge of others including your patients, their families and carers Respect your patients’ wishes, the decision regarding their care is ultimately theirs, we can but advise and support Dr Judith Carrier Cardiff University 2015

Dr Judith Carrier Cardiff University 2015 Thanks for listening Dr Judith Carrier Cardiff University 2015