Southend on sea PCT

Nurse-led Long term Conditions Management

60% of adults in England report a chronic health problem • • • • •

Out of 59m population: Diabetes Mellitus Asthma Arthritis 74%

affects 1.3m people affects 3.7m adults and 1.5m children affects about 8.5m in UK of those with long term medical condition in the UK have

1 or 2 problems; 26%

have

3 or more problems 8.8m

people in England have a long term illness that

severely limits their day to day ability to cope.

To improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008, through improved care in primary care and community settings for people with long term conditions.

The NHS and Social Care Long Term Conditions Model Infrastructure

Community Resources

Delivery System

Case Management Decision support tools and clinical information system (NPfIT) Health and social system environment Disease Management Supported Self care Promoting Better Health

Better outcomes

Empowered and informed patients Prepared and proactive health and social care teams

LTC Principles

• • • NHS and Social Care Long Term Conditions Model • • for the individual self care is key for the service its organisation Key elements include: • • whole system delivery matching resources to need Unique opportunity to be systematic and personal by working together collaboratively

LTC Management

Case Mgt Disease Management Level 3 Highly complex patients Level 2 High risk patients Self Management Population-wide Prevention Level 1 70-80% of an LTC population

LTC – key components of care

• Population Management • Effective registers and integrated records • Evidence based ‘care pathways’ • Disease management and care co-ordination • Self care/self management – with information and support • Active management of at risk patients • Primary/secondary/social care co-ordination

LTC and Self Care

Case management Disease management Self care

Level 3 Highly complex patients Level 2 High risk patients Level 1 70-80% of an LTC population

Themes for the future workforce

• Case management • Moving services into the community • Enabling and supporting – patient/professional partnership • Integrated, multi-disciplinary teams across health and health and social care

Community Matrons/Case Manager

• •

Selection Criteria

– a Community Matron is an experienced highly qualified nurse capable of working to an advanced clinical level diagnosing and treating complex conditions, working in partnership with the service user, all other stakeholders and professionals.

Objectives

– to optimise health and well being, reduce complications and inappropriate hospital admissions through a whole systems approach to care.

Long Term Conditions Community Matrons 2005-6

• Alan Sobratty RGN RMN DN DipN BSc(Hons) • Johanna Packer RGN BSc(Hons) DN • Gillian Judge RGN BSc (Hons) DN RM – All studying for MSc in Advanced Clinical Practice all are Extended and Supplementary Prescribers.

• 3 Health Care Assistants (NVQ 3) with social care backgrounds ( offered Associate Practitioner (NVQ 4).

Case management – a definition

‘A collaborative process which assesses, plans, implements, co-ordinates, monitors and evaluates the options and services required to meet an individuals health, care, educational and employment needs, using communication and available resources to promote quality cost effective outcomes’.

Case Management Society UK 2005

Case Management – the role

• To enhance the quality of life for clients/service users while potentially reducing the overall cost of disability.

• To collaborate with service users/clients by assessing facilitating, planning and advocating for health and social needs on an individual basis • Effective case management will directly and positively affect the social, ethical and financial health of the country and its population.

Case Management Society 2005

Case Managers

may be selected from any health or social care professional background but may not be able to personally provide for some of the advanced clinical needs of the service user but will function in a multiprofessional/multiagency team where these needs can be met. The service user will be managed by the professional who can meet the majority of their needs be they social or health and refer to team members for other aspects of care.

Strategic Health Authority Trajectories

Year 2005 2006 2007 2008 VHIUs Community Matrons 60 0 121 1.9

332 7.5

604 7.5

Case Managers 0 2.3

4.6

4.6

Referral criteria

• Adults who have two or more long term conditions including • Chronic Obstructive Pulmonary Disease • Coronary Heart Disease • Diabetes • A history of Falls • and/or multiple admissions to hospital • service extending in 2006 to neurological conditions e.g. Multiple Sclerosis, Motor Neurone Disease, Muscular Dystrophy etc

Referral route

• Open access from all health and social care professionals • Patient identification/case finding via PARR algorithm – hospital discharge process and retrospective analysis of hospital admissions by GP and through disease registers.