1. Complex Care Management In Practice Dunblane Tuesday 6 th November 2007

2. Pre 2003 Paper case notes Green recall sheet in case notes GP recalled patients using computer generated non specific recall system However Case notes not available for consultation Green sheets not updated Patients not sure why attending Patients recalled by disease

3. Patients Recall Multiple visits for patients with more than 1 condition Duplication of tests Patients time –travelling work etc Patients expenses Medical Care appeared disease centred not patient centred

4. Post 2003 Surgery started to become paper light Dr Dunlop had been developing a computer recall programme –Dunlop Recall Management (DRM) Trial of DRM on male patients with hypothyroidism

5. Co-prevalence

6. Comorbidity (the simultaneous presence of multiple chronic conditions)

7. During 2004 All patients with a Chronic Disease added to DRM All patients requiring follow up added to DRM i.e. Injections Baby 6 week check Routine blood tests IUCD checks Protocol developed for newly registered patients to be added to DRM

8. Complex Care Nurse Specialist Role Managing co-mobidity Proactive Recall and Team Management Delivering Patient Centred Scheduled Care efficiently by the Primary Care Team

9. Managing co-morbidity Co-morbidity varies with each diagnosis use of resources depends on the degree of co-morbidity (co-prevalance) rather than the diagnosis 30% patients on recall management (5034 patients)

10. Riverview Medical Centre 3 GP’s 2 GP Registrar’s 1 FY2  1 Practice Nurse  1 Health Care Assistant  1 Phlebotomist  2 District Nurses  2 Health Visitors Medical Staff  Practice Employed  Health Board Employed

11. Clinical Care Follow Up Plan Maps the patient journey: GP/ community / hospital Explains the patient journey: items of care Team members responsible for care Hands over responsibility to the patient Safety nets the deal with a further plan sent by post should the patient default (plan may be altered with revised information) Date of issue & any freetext  Read coded in primary care system CCFUP scanned into Docman before sending

12. Clinical Care Follow Up Plan - upper page

13. Clinical Care Follow Up Plan - lower page

14. Complex Care Nurse Specialist Tasks Creates new electronic patient management plans Trains staff how to use recall system checks missed deadlines report daily (results not back; recalls: DN) & advises health care assistant or admin staff which recalls can be sent by them; checks care plan details & appts of others – reassessing clinical need. Delivers chronic disease management at the higher skill level +/- prescribing, maximising own skills Defining and controlling practice resources

15. Missed Deadlines Report

16. The Team DRM updated by Dr’s PN and HCA during consultations Clinical Care Plans generated and given to DN’s, Phlebotomist and HV’s as appropriate Important to know the nursing team and their level of skills and competences Good rapport and communication skills

17. Plan Implementation - Community Clinical care plan returned to PN after consultation Information entered onto computer Clinical decisions made depending on results Medication alterations- contact patient or liaise with pharmacy for change of medication or alteration in dosages. Refer to other Health care services if required Arrange other tests/ investigations Planned review date and DRM updated GP intervention if required

18. WORKING TOGETHER Complex Care Nurse Specialist Role in scheduled primary care

19. Benefits For Patient Patient centered not disease centered care Minimising visits to surgery Reducing financial outlay  work and travelling Prevents duplication of tests and proceedures Improved relationships patients/ Gp’s and staff For PN / Surgery Less time spent on recall Improved working relationships -teamwork learning needs Identified Greater job satisfaction

20. Constraints Time IT programme needs further development Barrier to referrals for Nursing staff- although slowly resolving.

21. Finally:- If you have been…… Thanks for Listening