1. IMPROVING THE MANAGEMENT OF LONG TERM CONDITIONS AIMS 1For me to share with you –What weve learned so far –What we dont know yet 2 Your help to develop an improvement tool to support NHS implementation

2. I believe that improving the management of people with long term conditions through a systematic approach to care will: Optimise patients quality of life Improve patient & professional satisfaction Reduce unplanned admissions and LOS in hospital (target!) Encourage secondary to primary care shift of resources Reduce prescribing budgets

3. INCIDENCE OF CHRONIC DISEASE 17.5m people may be living with a chronic disease By 2030 incidence of chronic disease in the 65+ will have doubled 80% of GP consultations relate to chronic disease

4. Prescriptions increase with co- morbidities

5. Self Management Level 1 70-80% of a CDM pop POPULATION-WIDE PREVENTION Level 2 High risk patients Disease Management Level 3 Highly complex patients Case Mgt LTC Management

6. CASTLEFIELDS HEALTH CENTRE (UK) 15% reduction in unplanned admissions 31% reduction in hospital LOS (6.2 to 4.3) Total hospital bed days fell by 41% Significant savings Better patient experience Improved integration + more appropriate referrals

7. VETERANS ADMINISTRATION (USA) 35% reduction urgent care visit rate 50% reduction hospital bed days

8. EVERCARE (USA) 50% reduction unplanned admissions without detriment to health Significant reductions in medications 97% family and carer satisfaction High physician satisfaction

9. NHS-ADAPTED EVERCARE 3% of target population = 30% unplanned admissions for that age group many admissions avoidable (urinary tract infection, dehydration) 55-87% high risk population not accessing DNs & Social Services polypharmacy

10. THE TRANSFORMATION Care is Proactive Care delivered by a health care team Care integrated across time, place and conditions Care delivered in group appointments, nurse clinics, telephone, internet, e-mail, remote care technology Self-management support a responsibility and integral part of the delivery system Chronic Care Model Source: KPCMI [21] Complete Forms Deal with Acute Attack of Disease Counsel re: Lifestyle Changes Review Labs Access Social/Other Services Reassure Diagnose General Referral Review/Adjust Rx and Tx Routine Preventive Care Modify and/or Negotiate Care Plans Review History Review Care Plan Talk with Family Reinforce Positive Health Behaviours Traditional Model SICKNESS CARE MODEL (Current Approach - Physician Centric) Consultation 10 minutes

11. Acute system Treat the episode Dont make the connections And.......the patient is more likely to be admitted again

12. COMPONENTS OF EFFECTIVE CDM (1) Population management & risk stratification - (informing decisions) Effective registers and integrated records Evidence–based care pathways Disease management and care co- ordination

13. COMPONENTS OF EFFECTIVE CDM (2) Self care/self management - with information and support Active management of at-risk patients Primary/secondary/social care co- ordination

14. SO HOW DO WE MAKE THIS PARADIGM SHIFT? Start with better data extraction and information analysis to inform decisions Implement case management for patients with highest burdens of disease Implement NSFs for managing diseases and consider care co-ordination Support self management and self care Measure progress and achievement; and adjust process when necessary

15. WHAT WE DONT KNOW YET? When will incentives be aligned? Policy not yet fully articulated. Care co-ordination – how do we do? Impact on workforce – particularly nursing? What is our evidence for taking forward? What practice/ models work and where is it?

16. IMPROVING THE MANAGEMENT OF LONG TERM CONDITIONS AIMS 1For me to share with you –What weve learned so far –What we dont know yet 2 Your help to develop an improvement tool to support NHS implementation

17. BUT NHS MUST START TO IMPLEMENT! Can we work together to populate an implementation tool by harvesting what we already know?

18. Improving the Management of Long-Term Conditions Step 1/ Informed Decision Making Step 2/ Case Managing Patients with Highest Burdens of Disease in Community Step 3/ Coordinating Care for People With Chronic Disease Step 4/ Encouraging Patients to Become Confident and Informed About Managing Their own Condition Step 5/ Measuring Achievement

19. Step 1/ Informed Decision-Making Key Activities: 1.1 Identify and analyse population with LTCs 1.2 Plan services to support and care for them 1.3 Compare with current service provision 1.4 Commission services to support need and plug gaps

20. Step 2/ Case-Managing Patients with Highest Burdens of Disease in Community Key Activities: 2.1 Identify patients who are your frequent unplanned admissions 2.2 Combine their acute history with GP practices & Social Cares 2.3 Carry out clinical & social assessment in their home & agree Care Plan with them 2.4 Check & manage their medicines 2.5 Ensure delivery of Care Plan through multi-disciplinary team in primary care; and by orchestrating the care across secondary and social care boundaries.

21. Step 3/ Coordinating Care for People with Chronic Disease Key Activities: 3.1 Implement NSFs 3.2 Implement proactive, systematic review, recall & reassessment processes 3.3 Provide holistic care for patients with co-morbidity 3.4 Ensure seamless delivery of care pathway across organisational boundaries.

22. Step 4/ Encouraging Patients to Become Confident and informed about Managing Their own Condition Key Activities: 4.1 Provide patients with information about their condition(s), how to access services in NHS and social care, including OOHs 4.2 Refer patient to Expert Patient Programme 4.3 Signpost patient toward other support provided by voluntary and community sector, local authority, and others 4.4 Prescribe effective (combinations of) medicines 4.5 Provide tools to support home monitoring and testing 4.6 Engage patient throughout care pathway on improving self-management

23. Step 5/ Measuring Achievement Key Activities: 5.1 Assess baseline 5.2 Monitor progress 5.3 Adjust processes if necessary 5.4 Identify interventions that make a difference, 5.5 Gather effective practice 5.6 Extract learning and share widely

24. Populating the Process Model Name/ Step x 5 Question Learning Question 1.Review the Steps 2.You are only allowed 4 post-its of either colour 3.Write down your Learnings/ Questions IN CAPITALS 4.Name your post-it 5.Put your post-its on the correct whiteboards 6.Be prepared to explain your post-it question or learning in the review stage 7.Have a look at other learnings and questions on other steps

25. Populating the Model -marking your contributions for the review stage Name/ Step x QUESTION LEARNING 4.1 Jane B Mike A

26. Populating the Model -matching learnings to questions Name/ Step x Question Learning Question ? New Question

27. Review 1 Common, Special, Missing 2 New work and new ideas: building the new agenda around LTCs 3 Validity of 5-stage Generic Model 4 Next steps –sharing prototype with you and building new practice framework around LTCs 5 Thank you!