targeted, patient centred care planning for elderly with risk
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Targeted, Patient Centred Care Planning
for Elderly with Risk
Australasian Long-Term
Health Conditions Conference …Shaping our future health system
Hywel Lloyd
Targeted, Patient Centred Care Planning For
Elderly with Risk
Hywel Lloyd, Deb Connor & Pieter Degeling
All Taieri Health Centre Staff In Collaboration with Older Peoples Health
'Year of Care'
Target Population – Level 3 patients Most frail elderly at risk of hospital admission Aims Reduce Emergency Department Presentations Reduce Hospital Admissions Improve quality of Care Objectives Implement patient centred management plan focusing on risk as they perceived it to be
Otago OPJ 2 - Year Of Care Pilot
The Wellness Trajectory
Health Gain
Health Gap
Welln
ess
Time
Line A
Line B
The Practices
• Mosgiel Health Centre 5 Practices 10012 patients
• 6.5 FTE GPs
• 4 FTE Practice Nurses
• Practice Manager Nurse Manager Gordon Road Medical Centre - 1 Practice 2064 patients
• 1.5 FTE GPS
• 1 Practice Nurse
• 1 Receptionist/Manager
Outram Medical Centre 1 Practice 1682 patients
• 1.2 FTE GPS
• 1 Practice Nurse
• 1 Receptionist/Manager
• Middlemarch – Sattellite practice 0.2 GPs Rural Practice Nurses
Background
• Care Plus Implementation
• Frustrated
• Lack of specific focus
• Team working was not performing as well as possible
• Implementation was variable across the practices
• PHO struggled to achieve consensus at the practice level
• Wide interpretation of the inclusion criteria
• Strategic Vision Lacking
• No Analysis of process nor outcome of CarePlus programme
• Nationally 50% and 40% increase in ED and Hospital Admission
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources
and Policies
Community
The Organization of a General Practice
Wagner’s Chronic Care Model
Improved Outcomes
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Wagner’s Chronic Care Model
Improved Outcomes
Individualized (YoC) Plan
based model of care
Productive
Interactions
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources
and Policies
Community
The Organization of a General Practice
Optimising the Patient Journey
Re-design of
practice clinical
information
system
Workforce &
capital
Re-development
Individual
Self
Management
Mobilizing
local support
services
Re-design of
practice decision
support
systems
Routine review
and service
improvement
'Purposeful System for Delivering
'A Year of Care'
Delivery System
Re-Design
Indvidualised YOC
Care Planning
Paradigm Shift
Systematised approach to service provision.
Pieter Degeling
Helen Close
Deirdre Degeling
September 2006
Proactive Planned coordinated and adaptive Capable of focusing on both the health risks of identified populations and patients as well as their changing wants and priorities as they see these to be. Structured to facilitate routine improvement or adjustment review
Population Stratification
Level 1 : 1585 patients
Level 3 : 303 patients
Level 2 : 2524 patients
100%
0%
W e
l l n
e s
s
Population Wide Prevention Level 0 : 9346 patients
Support Management Clinical Management Self Management
Population Stratification - Enables
• Basis for understanding the population
• Improves Business & Financial planning
• Facilitates Workforce Analysis & Restructuring
• Re-Engineering the current didactic General Practice Model
• Targeted Care Planning
Sub-Stratification
• EARLi screening tool
• Applied as a telephone questionnaire
• Administered to Level 3 patients and Level 2 patients that are enrolled for Care Plus.
Lyon et al:
• Predicting the likelihood of emergency admission to hospital of older people:
• development and validation of the Emergency Admission Risk Likelihood Index (EARLi). FPAA 2007
Year of Care - Overview
• Patient generated care plan is central & focus of all
encounters
• Primary Health Care Nurses
• Facilitate Wellness Planning sessions,
• Record the individual's narrative highlighting goals &
risks and broker access to support services required to
attain these goals.
• Facilitate PDSA cycles to review goal attainment, &
plan adjustment.
SYSTEMATISATION for Individualised Care
Targeted Care Planning
Produce a written and electronic browsable care plan for the patient :
Baseline statement of wellness
Risks with plans to address these risks
Obstacles that need to be overcome to maintain wellness
Scenario setting and planning
What I need to do to stay well: daily weekly monthly
Warning signs and Triggers - Addressed with intervention plans
Future care setting requirements and plans
Classifications Medication Medical Warnings
End of Life wishes
Huge paradigm shift for everybody
Joint assessment of
Individual’s targets, goals
& risks
Personalised health plan
that specifies cycles of
activities that will
contribute to goal attainment
and address identified risks
Enacted plan
Joint outcome
review
Clinical management
Support services
Self management
Do
Study
Plan
PDSA improvement - An integral part of individualised care planning cycles
Act
Changes the practice of the practice through:
systematising the cycles of sequences of
events whose occurrence or non occurrence
will significantly affect quality outcome and
cost for an individual patient.
Year of Care Service Model.
Bi-Weekly Weekly Monthly Bi-Monthly
Individualized improvement cycles
Time
D
S S D
A
D
P A P
P
S
A
P
D S
A
Encounters initially face to face , later encounters may take the form of telephone
follow ups
Gains in locus of control & Wellness
Pilot Population
Mosgiel Health Centre 62 out of 89 invited patients were enrolled with YOC Gordon Road Medical Centre 17 out of 24 invited patients were enrolled with YOC
Quantatative and Qualitative Baseline established
• heiQ, PHQ-9, Patient Satisfaction & Experience • Emergency Presentations and Admission Data
Outcomes Measured against these baselines
Outcomes
Health-Directed Behaviour 1 – 4 2.66 2.87 16 of 49 = 30.77 % Positive and Active Engagement in Life 1 – 4 3.26 3.30 12 of 49 = 23.08 % Emotional Well-Being 1 – 4 1.81 1.66 15 of 49 = 30.77 % Self-Monitoring and Insight 1 – 4 3.30 3.44 16 of 49 = 23.08 % Constructive Attitudes and Approaches 1 – 4 3.63 3.63 8 of 49 = 16.33 % Skill and Technique Acquisition 1 – 4 3.12 3.20 23 of 49 = 46.15 % Social Integration and Support 1 – 4 3.45 3.46 23 of 49 = 46.15 % Health Service Navigation 1 – 4 3.63 3.68 9 of 49 = 18.37 %
Area Score Range Initial F up % Substantial Improvement
Aggregated heiQ results for Mosgiel Health Centre
Outcome Data – ED Attendances
Admission
Risk % EARLI
Patient Group N Pre YoC
Dec 2008 - Nov 2009
Post YoC
Dec 2009 – Dec 2010
47% Year of Care 16 0.44 0.31
Control 45 0.6 0.42
55% Year of Care 10 0.6 0.5
Control 21 0.62 0.81
Outcome Data – Admissions
Admission
Risk % EARLI
Patient Group N Pre YoC
Dec 2008 - Nov 2009
Post YoC
Dec 2009 – Dec 2010
47% Year of Care 16 0.94 0.81
Control 45 0.62 0.89
55% Year of Care 10 1.1 0.8
Control 21 1.05 1.29
Outcome Data – Bed Nights
Admission
Risk % EARLI
Patient
Group
N Pre YoC
Dec 2008 - Nov 2009
Post YoC
Dec 2009 – Dec 2010
47% Year of Care 16 5.88 3.5
Control 45 2.82 4.13
55% Year of Care 10 5.1 4.1
Control 21 5.76 7.05
Minimum prerequisites for implementing
Ability to stratify population to quite detailed level (PAT , EARLi) – accurate and consistent clinical coding required.
Analysable secondary care activity data sent to primary care
System that can support an electronic Care Plan
Staff with skills in person centred interactions with patients
Capacity (financially and personnel) to conduct Year of Care sessions
Enthusiastic staff within the team to drive the project forward to reason with the huffers and puffers and nurture the deep sighers!
Lessons Learned
Practice level impact - Emergence of a purposeful system
Other Lessons
It requires authorisation, commitment & support from a practice’s senior clinical leader who puts in time and indicates ownership. It’s not about adding something into what is already there. (Not 'Plug and Play') Nor is it about cutting something out of the existing weave and inserting a patch, but recasting the weave with a crochet hook) It is a complex re-learning process which needs to be carefully staged and whose effects emerge over time. We need to realign financial incentives.
Thank You...
Healthy Populatio
n
End Stage Death
Precursor Risk
At Risk Early Disease
Symptomatic Disease
Practice Clinical Information Systems
Advanced Disease
Chronic Disease Continuum
Information Strategy
The ability to analyse the population to identify patients - At risk: at all stages of the disease continuum - Why are they at risk, What are their risks - Manage intervention programmes, scheduled care episodes - Recall Prompts & follow up including non attenders - Monitor Performance: Process & Outcomes Measures
- Apply appropriate care plans at different disease stages
Level 1
Level 3
Population Stratification
Level 1
Patients with risk factors for developing a long term condition
Essential Hypertension
Pre- Diabetes
Smokers
BMI > 30
Level 1
Precursor Risk
At Risk Early Disease
Symptomatic Disease
Advanced Disease
Precursor Risk
At Risk Early Disease
Symptomatic Disease
Advanced Disease
Level 2
Level 2
Patients with one or two Long term Conditions
Level 3
Patients with three or more Long term Conditions
Health & Social Services Individual standing, voice and volition
Service Appropriateness & fragmentation
Flexibility, Acceptability
Availability, Accessibility
Incentives, Cost
Health Behaviours Alcohol/Drugs
Diet and nutrition
Physical activity
Sexual health
Smoking
Clinical Profile Disease severity
Co-morbidity
Existing poly-pharmacy and medication regimens
Patterns of service usage
Activities of daily living
Personal Profile Role models and norms inherent in cultural orientation
Self-efficacy/self esteem
Health locus of control
Health literacy
Health beliefs/attitudes
Living Circumstances Housing
Safety in the home
Living alone
Living with a dependent
Availability and quality of personal support
connectedness/interdependence with other
Socio-Economic Profile
Age, Gender , Employment status, Income
Cultural background
Environmental Factors
Personal safety
Transport
Exposure to pollution and other hazards
Adapted from Hawe P., Degeling D., & Hall J. (1990) Evaluating Health Promotion, Elsevier, Australia
Risk Assessment Criteria
Practice Level Impact
GP envolvement has moved.
At pilot initiation we had look warm support from 2/5 GP partners
Now all partners consider Year of Care to be part of core business and support
Year of Care plan at the core of GP - patient encounters
Centrality of nursing role within long term conditions acknowledged
Greater use of IT facilitating decision support systems.
Increase awareness of linking with community services.
Support for systems change re: scheduling, allocations of time, workforce allocation.
Workforce re-development
What is going well
• Care Plus is more targeted.
• Electronic Care Plan & Patient Held Record
• Individualised PDSA based care planning and service improvement.
• Practice wide PDSA based service improvement
• Couple 'co-dependency' Care Planning
• Skill uptake by patient on crucial aspects of their self management.
Marked shift in locus of control
• GP & Practice Nurse Buy In
• Work Redesign & Staff Training
• Development of financial Modelling Tool – linkage with CarePlus.
Year of Care – Lessons Learned
What needs further work:
System redesign to cope with distinct patient flows.
40% of encounters 10 minute GP consultations, 60% Year of Care model based management - Implications for scheduling, workforce assignment & space usage.
Improved data flow from secondary to primary care to trigger anlysis of variance (such as A&E attendance and/or admission) so that causes can be identified and individual care plans can be adjusted with the patient
Harmonise secondary care with YOC care planning
Linkage with NASC processes
Better inventory of wrap around services
Re-alignment of incentives for primary care.
Year of Care – Lessons Learned
Based on pilot findings DHB and PHO – commited to the rollout of YOC Model
across our region. Strategy will recognise that substantive redesign can only occur
on a practice by practice basis Consolidate work in Taieri Practices Select 4 more practices for detailed rollout and refinement of tools viz Stratification, electronic care plan variance recording & analysis, service harmenisation between primary and secondary care and related information flows. Resources allocated for staff and technical support to undertake the developmental work. Three year strategy Year 1 - PHO wide initiatives & rollout to 4 practices Year 2 - Consolidation within practices Year 3 - Initiate PHO wide payment system rollout
Where To From Here?
Year of Care Service Model.
Changes the practice of the practice through:
systematising the cycles of sequences of
events whose occurrence or non occurrence
will significantly affect quality outcome and
cost for an individual patient.
Re-design of
practice clinical
information
system
Workforce &
capital
Re-development
Individual
Self
Management
Mobilizing
local support
services
Re-design of
practice decision
support
systems
Routine review
and service
improvement
Practice level impact
Emergence of a purposeful system
Delivery System
Re-Design
Indvidualised YOC
Care Planning
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