Case management for long-term conditions

Transcription

1 Case management for long-term conditions Inconsistencies in the management of people with long-term conditions, along with high numbers of unplanned acute admissions, has led to the implementation of a case management system across Swansea. Deborah Thomas explains Photolibrary. This picture is posed by a model Deborah Thomas MSc, BSc(Hons), RGN, DN is a chronic conditions management programme manager at Swansea Local Health Board This article has been subject to peer review the World Health Organization (WHO), in highlighting the need for healthcare systems to prevent or manage long-term conditions, claimed that the focus of health care must move away from episodic care of seriously ill patients in hospitals towards continuous care by teams that combine specialist expertise and generalist capabilities (WHO 2002). National service frameworks encourage better management of single conditions, but the approach they take is disease-specific, and no such framework has been devised for people with multiple conditions. South Wales has an ageing population and a history of post-industrial unemployment, which place huge demands on its health and social care systems, so the management of long-term conditions in this area is particularly significant. In addition, Wales has the highest rates of long-term illnesses such as arthritis, and respiratory and heart conditions in the UK, and these illnesses account for many unnecessary emergency admissions to hospital (Welsh Assembly Government (WAG) 2007) (Box 1). Some parts of the health service in Wales provide support for people with long-term conditions, for example through well-established primary care teams and networks of other community providers such as pharmacists and therapists (Wilson et al 2005). The care offered by general practices to people with long-term conditions varies across communities, however, despite government efforts to reduce such inconsistencies (Seddon et al 2001). As a result, the need to change how long-term conditions are managed is urgent (WAG 2007). The pilot In 2005, a sample of five Swansea general practices revealed that 3 per cent of patients accounted for 59 per cent of emergency admissions. Many of these admissions were unnecessary, inappropriate and avoidable. They were due to inappropriate care, a lack of adequate support structures for people with long-term conditions and their carers in the community, and a tendency for emergency services to react to patients conditions rather than offer them preventative strategies. Welsh Assembly Government (2007) figures show that one in six admissions to hospital, and one in four 22 nursing management Vol 15 No 10 March 2009

2 Box 1. The profile of long-term conditions in Wales n there is a higher proportion of reported life-limiting long-term illness (23 per cent) compared with England (18 per cent), Northern Ireland (20 per cent) and Scotland (20 per cent). n one third of adults report having at least one long-term condition. n two thirds of people over 65 years old report having at least one long-term condition, while one third have multiple long-term conditions. n three quarters of people over 85 years old report having a life-limiting, long-term illness. n Most commonly reported long-term conditions in Wales are arthritis (14 per cent), respiratory (13 per cent) and heart conditions (9 per cent). National Public Health Service for Wales (2005) emergency admissions, are attributable to long-term conditions. Furthermore, people with multiple longterm conditions often remain in hospital longer than necessary because of the complexity of their care needs (Hudson and Moore 2006). Social factors, such as those associated with deprivation and poverty, contribute to the rise in emergency admissions (Hanlon et al 2000), as do demographic factors such as increasing age (Chan et al 2002), sol it ar iness, bereavement and inadequate social support for widows. In addition, unplanned hospital admission rates are higher among care home residents than in the community (Godden and Pollock 2001). For many years, patients with multiple long-term conditions and complicated needs have received unco-ordinated and fragmented care. As a result, they have missed out on opportunities to maintain or improve their health, and to avoid frequent or lengthy hospital admissions. To solve these problems, Swansea Local Health Board (LHB) initiated in April 2005 a long-term, or chronic, conditions management (CCM) pilot project to improve the management of long-term conditions across the area. The initiative built on the findings of pilots in other areas, including the Castlefields Health Centre project, in Cheshire, on the role of social workers and district nurses in improving care for older people (Improvement Found ation 2008), and the Evercare project, in England, on supporting people with longterm conditions (Department of Health (DH) 2005). It is also in line with the strategic vision for healthcare services in England and Wales described in the Wanless Report (DH 2002), in which people are encouraged to live more healthily and become more involved in their own health care. The steering group To launch the CCM pilot, a steering group of key stakeholders was set up. The members of this group are listed in Box 2. For the initial stage of the project, the steering group decided to take a case management approach to improve long-term condition management. Case management is a method of proactive care delivery in the community that involves identifying people who are at high risk of unplanned admission and who have complex and enduring health and social care needs. Case managers assess, design and deliver a personalised care plan for each individual in their case loads, and co-ordinate their patients journeys through health and social care services by acting as key workers (Hudson and Moore 2006). The main activities involved in case management are listed in Box 3. Five experienced nurses who wanted to take on autonomous roles in care co-ordination were recruited as case managers through adverts in local GP surgeries and regional newspapers. These case managers undertook an eight-week induction programme that included education and training in pharmacology and medicines management, clinical history taking, physical examination skills, familiarisation with local services and end of life issues. Five volunteer general practices were identified and staff at each were asked to select a caseload of patients assessed as being at high risk of unplanned admission. Box 2. Members of project steering group n A community nursing manager, an elderly care consultant doctor and a divisional nurse from secondary care, all from Swansea NHS Trust, now part of Abertawe Bro Morgannwg University NHS Trust. n A director of clinical development, service development manager, programme manager and practice development manager, all from Swansea Local Health Board (LHB). n A local GP. n A professor of primary care medicine from Cardiff University. n A freelance data analyst hired by Swansea LHB. nursing management Vol 15 No 10 March

3 Each of the case managers was then chosen to work with one of these caseloads to prevent unplanned admissions or readmissions. This initial phase of the project ended in March 2006, when it was evaluated quantitatively and qualitatively. Quantitative data showed that the number of emerg ency medical admissions among people over 50 years old and elderly care admissions in the pilot practices fell by 9.1 per cent, and that the number of hospital stays lasting more than one night fell by 10.4 per cent (Huws et al 2008). Qualitative evaluation showed that the case managers thought that the care they provided, which was based on diligent assessments and medication reviews, had led to new and more accurate diagnoses, better co-ordination of further care and the tailoring of services to suit the needs of individuals. This type of care, they said, had not been available previously. The benefits reported by the patients related to improvements in their quality of life rather than to the prevention of hospital admissions. The steering group concluded that, in introducing a role for case managers, the pilot enabled more time to be spent on assessing the individual needs of patients who struggle to live independently (Elwyn et al 2008). The CCM service After consultation with general practices across Swansea, the CCM service was introduced across the city in two phases during Under the scheme, 25 registered nurses, working the equivalent of 23 whole-time staff, and seven healthcare support workers, working the equivalent of Box 3. Case management activities n Creating personalised care plans that are based on need and reflect patients choice. n Providing patients with care in the least intensive but suitable settings. n Supporting effective primary care. n Focusing on patients with the highest burden of disease. n Working in partnership with acute, social and voluntary sector services. n Implementing integrated care pathways for patients. Adapted from Metcalfe (2005). Box 4. Aims of the Swansea chronic conditions management service n to help people manage their complex long-term conditions more effectively and to help them stay healthier for longer. n to reduce avoidable or long stays in hospital. n to provide accessible and prompt support for individuals in their homes. n To maximise or maintain the independence and quality of life of people with complex long-term conditions, their families and their carers. six whole-time staff, are employed by Swansea LHB and are based in 35 GP surgeries. These 25 case managers and seven support staff work seamlessly across health, social care and voluntary care organisations. Each of them has a caseload of up to 50 patients with multiple long-term conditions; many of the patients take multiple medications or have had falls. These patients tend to be particularly vulnerable because they have poor control over, and experience frequent exacerbation of, their conditions. Many of them live alone and are isolated socially with little support. The CCM service aims to be pro-active rather than reactive, by empowering them (Box 4). Swansea CCM service staff pro-actively identify suitable clients for case management from emergency admission data sent weekly from Abertawe Bro Morgannwg University NHS Trust. Referrals are also taken from GPs. To ensure that the profile of the new service was raised among organisations in the local health, social care and voluntary sector communities, the referral criteria was not defined at first. As a result, there was a large number of referrals, many of which were judged inappropriate to the remit of the service. Latest figures Data on the number of emergency medical admissions among people over 50 years old and care of the elderly admissions for 2007/08 demonstrate a 10.4 per cent reduction compared with the same period in 2006/07, an 11.0 per cent reduction compared to 2005/06, and an 11.2 per cent reduction compared to 2004/05. This equates to 1,086 fewer admissions a year among patients registered at the 35 surgeries across Swansea in 2007/08 than in 2004/05, and demonstrates that emergency admissions had reduced further since the pilot project was completed. Overall, patients are now cared for in the most appropriate places by the most appropriate professionals, and unnecessary emergency admissions are avoided. Emergency medical and elderly care admiss- 24 nursing management Vol 15 No 10 March 2009

4 ions in 2007/08 compared with previous years are shown in Table 1. There have been several recent developments within the CCM service and these are described below. Telehealth pilot There are a growing number of technological approaches to support people with long-term conditions. These include vital sign-monitoring technologies, lifestyle monitoring, reminder systems, telephonebased care management programmes and kiosks for health and wellbeing. The Swansea CCM team are undertaking a telehealth pilot, which involves patients using a range of self-monitoring devices covering four main functions, depending on each individual s condition: blood pressure, weight, blood glucose and pulse oximetry. Falls prevention Much of the work by healthcare support workers concerns the assessment and prevention of falls. Patients identified as being at high risk of falling were unable to reach community falls classes. For this reason, the CCM service healthcare support workers have undertaken a trainer s course in chair-based exercises (CBEs) to improve posture, joint movement, blood circulation and performance of daily functional actions. These exercises have been shown to help older people to develop and maintain their independence and mobility. Service staff now deliver CBE training to patients in their own homes and are considering the delivery of it to people in sheltered housing. Oxygen assessment Before the CCM service began, the prescribing of oxygen was unco-ordinated. Now, all oxygen apart from palliative care oxygen, the prescribing of which remains within the remit of GPs, is prescribed by respiratory nurse specialists after assessment by CCM staff. Around 600 patients in Swansea now receive home oxygen therapy in a scheme involving the LHB and Abertawe Bro Morgannwg University NHS Trust. All patients who may need oxygen are referred to the CCM nurses attached to their GP practices and are reviewed on two separate occasions. If their arterial oxygen saturation levels are less than 92 per cent on both occasions, these patients are referred to the respiratory nurse specialists at the trust. Patients are reviewed regularly and, if their oxygen saturation levels are found to be more than 92 per cent, they are referred to the respiratory nurse specialists with a view to stopping oxygen therapy. This system has ensured that oxygen prescriptions are more appropriate, and the monthly spend on oxygen across the locality has decreased by 12,000. Table 1. Comparisons of emergency medical and elderly care admissions between 2004 and 2008 Number of admissions each month over four years Percentage change 2004/ / / / / / / / / /08 April May June July August September October November December January February March Total 9,687 9,664 9,603 8, nursing management Vol 15 No 10 March

5 Computer-based information Informing Healthcare, a WAG programme to improve health services by introducing new ways to store, access and use information, worked with healthcare professionals and data analysis experts to develop a computerbased information tool, called PRISM, that stratifies each person in a practice populat ion into one of four levels according to his or her risk of emerg ency admission. The information can be used by community nurses and social services staff to provide additional care, to increase support or preventative treatments that help prevent patient deterioration, and to keep people out of hospital. Involving key stakeholders as early as possible This is the single most important lesson learned during the implementation of the CCM service. The steering group comprised managers from the former Swansea NHS Trust but did not include clin icians such as community nursing staff. This led to confus ion and uncertainty among other clinicians, such as district nurses and health visitors, about the roles of the case managers. This confusion and uncertainty has diminished as the clinicians have become accustomed to the structure of the service, but such concerns should have been anticipated and thereby prevented. Anticoagulant monitoring In August 2007, the prescribing team at Swansea LHB undertook an audit of local patients who use warfarin. This found that there were more than 300 such patients who may not have been monitored and that monitoring and prescribing responsibilities had become separated. Consequently, independent prescribers from the CCM service are currently being trained to run anticoagulation clinics while maintaining a reduced patient caseload. A pilot project to test these clinics is being discussed. Lessons learned Many lessons have been learned during the development, piloting and introduction of the Swansea CCM service, and some of these are described here. Raising the profile of the new service After the service was introduced, the case managers were inundated with referrals, many of them inappropriate, from health and social care service providers, and from voluntary agencies. As a result, the referral criteria was changed. Now, patients suitable for case management are identified through hospital admission data and referrals from GPs. Referrals from other care professionals are welcome, however, after assessment of the patients clinical records. If the case managers think that patients would not benefit from case management, they inform the referrers. This system has enabled the case managers to concentrate on the most vulnerable patients, who are likely to benefit most from the increased support. References Chan DK, Chong R, Basilikas J et al (2002) Survey of major long-term iilnesses and hospital admissions via the emergency department in a randomized older population in Randwick, Australia. Emergency Medicine. 14, 4, Department of Health (2001) Medicines and Older People: Implementing medicines-related aspects of the NSF for older people. uk/en/publicationsandstatistics/publications/ PublicationsPolicyAndGuidance/DH_ Department of Health (2002) Securing Our Future Health: Taking a long-term view. The Wanless report. Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_ Department of Health (2005) Assessment of the Evercare Programme in England : Executive summary. en/publicationsandstatistics/publications/ PublicationsPolicyAndGuidance/DH_ Elwyn G, Williams M, Roberts C et al (2008) Case management by nurses in primary care: analysis of 73 success stories. Quality in Primary Care. 16, 2, Godden S, Pollock AM (2001) The use of acute hospital services by elderly residents of nursing and residential care homes. Health and Social Care in the Community. 9, 6, Hanlon P, Walsh D, Whyte BW et al (2000). Influence of biological, behavioural, health service and social risk factors on the trend towards more frequent hospital admissions in an elderly cohort. Health Bulletin. 58, 4, Hudson AJ, Moore LJ (2006) A new way of caring for older people in the community. Nursing Standard. 20, 46, Huws D, Cashmore D, Newcombe RG et al (2008) Impact of case management by advanced practice nurses in primary 26 nursing management Vol 15 No 10 March 2009

6 Allowing the new service to evolve The service has changed since its inception and will continue to evolve as patient needs are ident ified. It is essential that staff are aware that change is a fundamental aspect of long-term conditions management, and that they will need to be flexible and adaptable if they are to meet the changing healthcare needs of the population. A multidisciplinary approach is important Effective and efficient long-term conditions management cannot be implemented without the contribution of professionals from GPs, intermediate care and community nursing service providers, secondary care colleagues and the voluntary sector. By establishing good working relationships with such care professionals, the CCM service has maximised its effectiveness. Effective medicines management is crucial Department of Health guidance states that problems with medicines are implicated in between 5 and 17 per cent of hospital admissions (DH 2001). But, among vulnerable people such as those over 75, the figures may be even higher given that 36 per cent of people over 75 take four or more prescribed medicines and 80 per cent take at least one (Medicines Partnership 2002). In Pirmohamed et al s (2004) prospective analysis of adverse drug reactions in the UK, moreover, the authors found that such reactions may lead to more than 10,000 deaths a year. The case managers review patients medication as part of their initial assessments, sometimes with pharmacists if regimens are complicated. These reviews are in-depth evaluations, each of which is defined as a structured, critical examination of a patient s med icines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste (Medicines Partnership 2002). Conclusion Healthcare services depend on the informed choice of patients. They involve the examination of issues such as non-concordance, risk taking, and care processes and pathways to create cultures and philosophies that support patients effectively. Long-term conditions affect not only the quality of patients lives, but also the healthcare services they need, because patients with such conditions are more likely to visit their GPs, be admitted to hospital and remain there for longer. Effective long-term conditions management offers opportunities for improvements in patient care and service quality, and for reducing costs. It supports patients in managing their own conditions to the point at which crises or deterioration can be prevented, so that the overall quality of their lives improves nm care on unplanned hospital admissions: a controlled intervention study. British Medical Council Health Services Research. 8, May, 115. Improvement Foundation (2008) Castlefields Health Centre: Runcorn. view/castlefields-health-centre-runcorn Medicines Partnership (2002) Room for Review: A guide to medication review. The agenda for patients, practitioners and managers. Medicines Partnership, London. Metcalfe J (2005) The management of patients with long-term conditions. Nursing Standard. 19, 45, National Public Health Service for Wales (2005) A Profile of Long-term and Chronic Conditions in Wales. gov.uk/topics/health/publications/health/ reports/profilelongtermchronic?lang=en Pirmohamed M, James S, Meakins S (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. British Medical Journal. 329, 7456, Seddon ME, Marshall MN, Campbell SM et al (2001) Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Quality in Health Care. 10, 3, Welsh Assembly Government (2007) Designed to Improve Health and the Management of Long-Term Conditions in Wales: An integrated model and framework. documents/chronic_conditions_english.pdf Wilson T, Buck D, Ham C (2005) Rising to the challenge: will the NHS support people with long-term conditions? British Medical Journal. 330, 7492, World Health Organization (2002) The World Health Report 2002: Reducing risks, promoting health life. WHO, Geneva. nursing management Vol 15 No 10 March