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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. Drawing on evidence to support practice-some resources
TRIP database-
NICE-Clinical Knowledge Summaries-
NICE guidelines-
SIGN-
Clinical Evidence-
Cochrane Collaboration-
Campbell Collaboration-
Joanna Briggs Institute-
University of York Centre for Reviews and Dissemination-
Dr Judith Carrier Cardiff University 2015

25. 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

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