1. Facing the Care Challenge Practice A pathway approach to implementing NICE guidance A nurse led model Susan Oliver MSc FRCN Nurse Consultant Rheumatology Independent

2. Stepping into new territory a nurse led inflammatory arthritis model Exploring nursing leadership driving improvements in clinical care

3. Overview Example of good practice - rheumatology service development Commissioned service in Oldham – Collaboration between specialist and community services – Transfer of patients to a community based model Patient experience and needs Framework, guidelines and workforce

4. Rheumatology Discuss the Rheumatoid Arthritis Example (RA) Rheumatological conditions e.g. – Inflammatory forms of arthritis, systemic lupus, scleroderma Inflammatory joint diseases (3%) – Rheumatoid Arthritis, Psoriatic Arthritis – Expensive treatments, quality of life impact, co- morbidities – Need to manage disease control

5. Oliver & Bosworth (2010) The user patient journey. In Rheumatology Evidence based practice for physiotherapists and occupational therapists. Elsevier.

6. Nursing model Team approach Improve symptom relief & enhance self management Work to improve functional ability & promote independence Provide Education, enhance concordance and reduce risk Point of access for team support Increasing role in assessment, monitoring & screening for treatments Supporting social & psychological adjustment to disease

7. Rheumatology Nursing Clinical Nurse Specialists – Studies have demonstrated safety and efficacy equivalent to a junior doctor with ↑ patient knowledge 1 – Manage triage and early arthritis clinics 2 – Cost effective & valued by patients in provision of telephone advice line support 3, 4 – Drug monitoring and well being 5 – 28% are nurse prescribers 6 1. Hill (2003) 2. Gormley et al, (2003) 3. Hughes et al (2002) 4. National Audit Office Report (2010), 5. Ryan (2006) and 6. RCN (2009)

8. Change the way we manage capacity The essence of nursing role in rheumatology but...drivers must Understand the demand – Measure it – Plan capacity to account for variation in demand – Plan for no waiting list or queue = no delay for nursing care/team approach Reduce the number of steps in the process – remove non-value adding activities Reduce the variation in capacity – Reduce the number of queues at each step – Match different team members pathway input Improve bottleneck productivity = throughput

9. Rationale for evidence based care Pathways More...real change in the pipeline 1 – Commissioners/Consortia lack of knowledge/time/interest – Regional variances in pathways of care – Need to optimise efficiency and highlight quality 2 Matching capacity with demand Structured and rigorous focus on; – Activity (N/FU ratio) – Costs and outcomes Quality indicators and PROMs – Use of Evidence based care/guidelines 1. Lord Darzi High Quality Care for all (2008) 2. Equity and Excellence, Liberating the talent of the NHS,(2010).

10. Why pathways - patient Transparency of pathway Ability to plan and consider future issues Aids documentation and recall of their patient journey Key points in pathway linked to assessment and outcomes Quality of Life an important and valued indicator 1 References: Lord Darzi Review High Quality Care for All (2008)

11. Why pathways – clinical Greater use of teams expertise Potential to reduce variances in care – Document clearly exceptions to routine path Identification of true versus perceived bottlenecks and long waits Less ‘faces’ but more effective interactions Bridges gaps between provision – Primary/secondary – NHS/Voluntary sector

12. Why pathways - financial Provider can predict more clearly activity and resources required All team members providing care are incorporated & costed – Implications regarding cheapest competent practitioner Costs can be more accurately predicted/plotted against patient flows Commissioners can identify – Activity + Costs + Outcomes – Variances can help future contracting/financial changes Managing capacity and demand

13. Healthcare delivery 2010 and on.....

14. The future in healthcare delivery Deliver improved services with same amount (or reduced levels) of income More for less + demonstrate strong evidence of quality and value of steps in service delivered Identify the patient experience and outcomes

15. Optimising patient care Transparency Equity of access The Foundations Patient Experience

16. The Healthcare practitioner’s perspective

17. Patient Stories v standards and guidelines Evidence Based Care Standards Guidelines

18. First steps Referral pathway Patient Positive messages Musculoskeletal information Worthwhile seeking clinical opinion Primary Care Team Knowledge of musculoskeletal conditions Access to succinct and evidence based referral criteria according to local service Specialist Team Referral criteria that apply to service and accessible Support and good communication options for Primary Care Teams Service re-design to ensure effective pathway The King’s Fund Report (2009) The patient and healthcare professionals perceptions of Rheumatoid Arthritis Care. London

19. Putting evidence into practice

20. The Nursing Model Biopsychosocial model of care Optimal management achieved with a holistic and patient centred approach 1 – Agreed goals – Negotiated treatment plans 2 – Informed decision making 2 – Self management & patient preferences 2 – Transparent framework of support 1. Richards & Coulter Is the NHS becoming more patient-centred? Picker Institute. London. (2007) 2 Coulter A and Ellins (2007) Effectiveness of strategies for informing, educating and involving patients. BMJ. 335. 24-27

21. Pennine MSK model for RA Based upon NICE RA management guidelines (2009) Diagnosis by Consultant Rheumatologist Referral to nurse led clinics Intensive management 6 weekly assessment + telephone consultation + rapid access service Management based on disease control Red Flags to guide referrals back to medics Protocol driven treatment plan Data collection using the EMIS system Patient held record Disease control Reduce follow up care when stabilised to annual review with access to telephone review+ rapid access service Review by MDT according to need. Information on Pennine MSK http://www.pmskp.org/index.html

22. Framework Patient pathway – All steps in pathway outlined – Each drug outlined with risks and benefits + monitoring – Exceptions and red flags etc – referred back to physician Patient Group Directions (PGD) and policies – Symptom and disease control All clinicians actively involved with pathway A staged and integrated approach to transfer of patients from specialist to community services

23. NICE RA management principles Implementation Required re-design of services with investment Patient required early and prompt review until disease control Heavy front loaded activity required service re-design Frameworks for nursing practice – Development of nursing competencies Plan for enhancing nurse specialist expertise Independent nurse prescribers, joint injection – Policies and patient group directions Structured patient pathway essential – Capacity and demand – Competencies at each stage of pathway – Clarity re patient on or off pathway and when to seek medical advice

24. The Nursing issues – started with Overall accountability Nurse Consultant (Partner) One PT Nurse Consultant (Independent – contracted service) 1 Part Time(PT) Nurse Specialist in rheumatology (band 8) 2 PT nurses working in service who required additional training (band 6) – Osteoporosis and practice nurse /community nurse expertise 2-3 Healthcare workers – chiefly deployed in orthopaedic, triage and pain services Good administrative support and management

25. Patient clinical assessment cycle Disease Assessment Disease Assessment >3.2 Dose escalation/Treatment change Disease Assessment <3.2 Rapid access Telephone Support Access to rapid symptom control Flare management Annual Multi- professional team support Systematic and equitable? Clarity of pathway and management? Triage, rapid access and effective use of the phone for all? Outcomes? Patient experience? Time to access rapid advice? Equity of access to MDT support? Value of approach and strategies? Annual review?

26. Innovation example Patient benefits & Cost effective Background: Specialist services cost - day care activity patients attending for intramuscular methotrexate (once a week) 30 patients tariff (£655 pp)day case tariff. Innovation: Community education day all patient invited – Education on conversion from IM to Subcutaneous methotrexate. – Group sessions of 6 with nurse to teach SC administration – Presentations by team and supplier of new treatment option (delivered to patients home) – PCT made significant cost savings/patients care improved

27. On-going transfers Status > 800 <2000 patients transferred from specialist services to community services Chiefly managed by nurses following diagnosis Treating to target according to NICE principles Tracking on or off pathway Patient involvement Customer Excellence Award (2009)

28. Demonstrating the value of new models Historical challenges in demonstrating the unique value of the nurse specialist in improving patient care (Oliver and Leary 2010). Computer system – templates and data systems – Proposed new electronic system being considered incompatible with previous system Continuous education training/updates to team to maintain pathway approach – Breaking old habits sustaining new ones New policy changes/resource/funding Training of nursing team – New substantive part time senior rheumatology lead nurse (PT) Undertaking joint injection course – 1 Nurse undertaking Prescribing course & 1 on waiting list for NPC – 1 nurse attending rheumatology masters & 1 BSC course on chronic disease nursing Oliver and Leary (2010) Musculoskeletal Care, [8] 3, 175-177

29. Opportunities Nursing workforce – Various expertise provided additional patient benefits Competencies in; cardiovascular disease and assessment osteoporosis management Orthopaedic referral and assessment Newly appointed nurse – linked to academic unit to support on- going training and development Enhanced participation and standards of care with all multi-disciplinary team Patient input vital to service development

30. Issues Evidence based practice balanced with health policy drivers/costs Disease specific evidence versus generic evidence – Still limited research in specific disease areas undertaking new models of care Targets and quality indicators – Data capture of benefits traditionally focus on target driven areas – 80% of referrals seen with 3 weeks. – Patient Satisfaction Surveys regularly undertaken – (see website) http://www.pmskp.org/index.htmlhttp://www.pmskp.org/index.html

31. Evaluation Frequent reviews of service and team working to: – Review deviance from pathways and planning needs – Develop robust quality indicators Include tools for ethnic and minority needs – Improve patient involvement Consider patient population – Review governance and competencies – Demonstrate cost effectiveness New frameworks/commissioners Data collection should show benefits re steps of pathway – quality indicators, patient experience and cost effectiveness (QUIPPs). – Consider the impact of high quality administrative support to nurse activity

32. Conclusion Nurse Led Models Evidence in the provision of specialist disease specific nursing interventions remain scanty Nurse Prescribers benefit patient journeys in managing risk and advising GPs Protocols/policy/PGDs labour intensive but essential Patient outcomes and cost effectiveness are not mutually exclusive.

33. Discussions