Download - Complex Care Management In Practice
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Complex Care Management In Practice
Dunblane
Tuesday 6th November 2007
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Pre 2003
Paper case notes Green recall sheet in case notes GP recalled patients using computer generated
non specific recall systemHowever
Case notes not available for consultation Green sheets not updated Patients not sure why attending Patients recalled by disease
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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
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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
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Co-prevalenceco-prevalence of disease in Male patients with
hypothyroidism
0
2
4
6
8
10
12
1 2 3 4 5
number of major disease classifications(incl hypothyroid)
nu
mb
er
of
pa
tie
nts
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Comorbidity(the simultaneous presence of multiple chronic conditions)
Co-morbidity in male patients with hypothyroidism (n=28)
0
2
4
6
8
10
12
14
16
none BP CHD COPD Asthma Cancer Stroke Diabetes Epilepsy MentalIllness
other
major disease category incidence
num
ber
of p
atie
nts
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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 checkRoutine blood testsIUCD checks
Protocol developed for newly registered patients to be added to DRM
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Complex Care Nurse Specialist Role
Managing co-mobidityProactive Recall and Team ManagementDelivering Patient Centred Scheduled Care efficiently by the Primary Care Team
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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)
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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
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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
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Clinical Care Follow Up Plan- upper page
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Clinical Care Follow Up Plan- lower page
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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
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Missed Deadlines Report
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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
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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
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WORKING TOGETHERComplex Care Nurse Specialist Role in scheduled primary care
PatientScheduled Care : Unscheduled Care
?nurse advice
Receptionist appt <48hr NHS 24 Nurse Advice
checks patient mgt plan
?dr advice routine ?links Hospital Admission
Appointment System
Routine Housebound Same day/48hr
GP Tel Consultation/Triage Advice +/- script ; appt
patient tel
SCI Gateway
data added risk mgt (add follow up codes
where required) tel direct access
Posted to Patient GP specialist and/or
Clinical Care Follow Up Plan
Recall
Electronic Patient Management Plan -contract data -red flag symptoms -other clinical follow up (eg IUCD,B12); referral pathways
Electronic Patient Record
AUDIT
Fast track Intermediate care
(Clinic or Nurse Specialist) eg
EPU;Physio (low back pain) ; other
consultant opinion
risk mgt
Complex Care Nurse Specialist reports and letters
Missed Deadlines Report
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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
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Constraints
Time IT programme needs further development Barrier to referrals for Nursing staff-
although slowly resolving.
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Finally:-
If you have been……
Thanks for Listening