1. Chronic Disease Management Delivering a system in Primary Care October 2002

2. Why a systematic approach to CDM? Lots of work in ordinary consultations Involvement of team is necessary All doing similar things NSF standards to be met Need to deliver care from an evidence base Patients have expectation of standard of care Equity of care Other targets e.g. new contract, PCT targets etc

3. Which disease areas? CHD Hypertension Diabetes Asthma Epilepsy Thyroid disease Others to come

4. What is needed to make it happen? Some defined standard e.g. NSF for CHD A systematic approach Some clinical protocols

5. The systematic approach Accurate registers of those with active disease manual or computer Accurate identification of those at risk Registers actively used and validated A committed clinical team meeting regularly Agreement re appropriate management

6. Systems needed for 2 groups Those with existing disease Those with a new/future diagnosis

7. About Disease Registers To organise disease management effectively and efficiently To measure clinical outcomes and performance of a target group Provide epidemiological data of prevalence/incidence to inform needs assessment

8. Identification of Patient Group Agree what constitutes the disease e.g. CHD – Heart failure, non-rheumatic AF, angina as a clinical syndrome, MI – Positive EST/thallium scan – Arterial disease – Coronary artery surgery/revascularisation

9. Identifying data Know how this data is recorded in your current system, e.g. manually, computer, Read code sets Agree future recording system Agree how new diagnoses will feed into system

10. Strategies for finding patients eg with CHD Search for those with diagnosis e.g. IHD Search other known high risk groups e.g. diabetics Drug searches – nitrates, low dose aspirin, warfarin, nicorandil, digoxin, statins Opportunistic case finding – clinician recall, other PHCT members, pharmacist, reception, prescriptions, posters, hospital discharge letters, correspondence Validate existing registers – should find 3-5% practice population

11. Which model of care? Special clinics? Protected time? Opportunistically, but with structure? Targeted contact? What about those with other chronic disease? Joint review e.g. CHD/Diabetes Length of appointments, frequency of attendance

12. Call and Recall System How will this be managed? Who will manage this system? Invitation Non-responders Housebound

13. Who will be involved? Nurses Doctors Support staff ? resourcing

14. New/future diagnosis How will these patients be picked up? How will they be added to register? When/how often should they be seen?

15. Evidence based interventions Protocols/guidelines e.g. for CHD Blood pressure management Lipid management ACE inhibitors for LV dysfunction Beta-blockers for those post-MI Warfarin/aspirin for AF Tight diabetic control Life style interventions

16. Protocols Evidence based Comfortable to in house situation Specific and clear User friendly Embraced by all Support nurses at higher level of autonomy to initiate and change treatments Inclusive of structure and process Dynamic and ever changing!

17. Tools Dedicated record card/computer template Invitation letter Identification system/register Recall facility Risk calculation system Evidence based, practice agreed protocol for clinical management

18. Audit Constant! Around structure, process and outcomes Shared Basis for clinical meetings Validates/adapts and changes clinical practice