Transcript DRM (Dunlop Recall Management)

Complex Care
Management In
Practice
Dunblane
Tuesday 6th November 2007
Pre 2003
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Paper case notes
Green recall sheet in case notes
GP recalled patients using computer generated
non specific recall system
However
Case notes not available for consultation
Green sheets not updated
Patients not sure why attending
Patients recalled by disease
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-prevalence
co-prevalence of disease in Male patients with
hypothyroidism
12
number of patients
10
8
6
4
2
0
1
2
3
4
number of major disease classifications(incl hypothyroid)
5
Comorbidity
(the simultaneous presence of multiple chronic conditions)
16
Co-morbidity in male patients
with hypothyroidism (n=28)
14
number of patients
12
10
8
6
4
2
0
none
BP
CHD
COPD
Asthma
Cancer
Stroke
major disease category incidence
Diabetes Epilepsy
Mental
Illness
other
During 2004
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All patients with a Chronic Disease added to
DRM
All patients requiring follow up added to DRM i.e.
Injections
Baby 6 week check
Routine blood tests
IUCD checks
Protocol developed for newly registered patients
to be added to DRM
Complex Care Nurse
Specialist Role
Managing
co-mobidity
Proactive Recall and Team Management
Delivering Patient Centred Scheduled
Care efficiently by the Primary Care Team
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
Clinical Care Follow Up Plan
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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
Clinical Care Follow Up Plan
- upper page
Clinical Care Follow Up Plan
- lower page
Complex Care Nurse Specialist Tasks
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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
Missed Deadlines Report
The Team
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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
Plan Implementation - Community
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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
WORKING TOGETHER
Complex Care Nurse Specialist Role in scheduled primary care
Patient
Scheduled Care : Unscheduled Care
?nurse advice
appt <48hr NHS 24 Nurse Advice
Receptionist
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
Clinical
Care
Follow Up
Plan
GP specialist and/or
Recall
Electronic Patient Management
Plan
-contract data
-red flag symptoms
-other clinical follow up (eg
IUCD,B12); referral pathways
Electronic Patient
Record
AUDIT
risk mgt
Missed
Deadlines
Report
Complex Care Nurse Specialist
reports and letters
Fast track
Intermediate care
(Clinic or Nurse
Specialist) eg
EPU;Physio (low
back pain) ; other
consultant
opinion
Benefits
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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
Constraints
Time
 IT programme needs further development
 Barrier to referrals for Nursing staffalthough slowly resolving.
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Finally:-
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If you have been……
Thanks
for Listening