Working with you to make Highland the healthy place to be

Highland NHS Board 2 June 2009 Item 5.3 POLICY FRAMEWORK FOR LONG TERM CONDITIONS/ANTICIPATORY CARE Report by Alexa Pilch, LTC Programme Manager, on behalf of Dr Ian Bashford, Medical Director and Elaine Mead, Chief Operating Officer The Board is asked to: Note the strategic approach of the service improvement work to deliver the key work streams of the Long Term Conditions Collaborative Endorse the framework for taking forward anticipatory care across NHS Highland 1 BACKGROUND AND SUMMARY The Long Term Conditions Collaborative (LTCC) was launched in April 2008 to support the delivery of sustainable improvements in patient centred services for people with Long Term Conditions (LTCs). These improvements are crucial to the delivery of timely, safe, effective and efficient services for the people in NHS Highland who have one or more long term condition. Long Term Conditions currently account for approximately 80% of GP consultations and 60% of hospital bed days, and an ageing population will increase the prevalence of LTCs. Without significant redesign of the way we manage Long Term Conditions, services will become inappropriate, inefficient and unsustainable in the future. The 3 main work streams of the Long Term Conditions Collaborative are: Anticipatory Care Condition Management Self Management This paper summarises the strategic framework for delivering these three work streams across NHS Highland, with a particular focus on the approach for rolling out anticipatory care across the region. 2 ANTICIAPTORY CARE 2.1 Context Anticipatory care is one of the key work streams of the Collaborative agenda to enable Health Boards to be more proactive in the management of people with Long Term Conditions, particularly for those with multiple, complex needs who are at highest risk of emergency admission and/or readmission to specialist services. Anticipatory care planning is a process of discussion and reflection about personal choice, values and preferences for future treatment in the context of an anticipated deterioration in the patient s condition, with potential loss of capacity to make decision and communicate these to others. Within NHS Highland we are seeking simply to use the term anticipatory care to identify and proactively plan care for people with long term conditions. Initially this will focus on patients with complex needs who are at high risk of hospitalisation. Working with you to make Highland the healthy place to be

The core elements of anticipatory care planning for people with complex needs are already incorporated within the Gold Standards Framework Scotland (GSF 2006) being followed for palliative care patients. Within NHS Highland we aim to adopt and extend this approach for people with Long Term Conditions. This will involve a significant change in how primary care services are delivered by the extended primary care team and other agencies. Patients can expect to be cared for in their home and their needs anticipated before reaching a crisis point which may result in a hospital admission. 2.2 Approach It is proposed that an Enhanced Service is developed to take forward a standardised approach to anticipatory care planning. The use of an enhanced service will allow NHS Highland to influence the way in which anticipatory care is rolled out and implemented across all localities. Additionally, it will recognise the time and resource implications required to develop anticipatory care plans and will remunerate GP Practices accordingly for this. The benefits of an agreed approach to anticipatory care will include the production of standardised documentation which can be shared centrally to ensure access to anticipatory care plans 24hrs a day by all healthcare professionals providing direct care to these patients. The initial focus for anticipatory care will be patients identified through SPARRA (Scottish Patients At Risk of Readmission and Admission) as being at greatest risk of admission or readmission. Additionally, all residents of nursing and residential homes will have an anticipatory care plan developed. In order for anticipatory care planning to be truly effective, a multidisciplinary and multiagency approach must be adopted to ensure all aspects of a patient s health and social care needs are considered and actions noted in the event of a deterioration of their condition. In many areas of NHS Highland there is a requirement to undertake some redesign work or team building to ensure the extended community care team is in place to adopt this multidisciplinary/multiagency approach. It is therefore proposed that the roll out of anticipatory care is delivered in two phases to allow time for the fostering of effective multidisciplinary/agency team working in all areas across NHS Highland. Phase 1: Practice Teams will be asked to produce an Anticipatory Care Patient Alert (ACPA) form for the top 1% of their practice population identified by SPARRA as being at greatest risk of (re)admission. In addition, Practices will be asked to complete an ACPA for all care home residents within their catchment area. The ACPA is based on similar principles to the existing Palliative Care Patient Alert Form and identifies some key actions or decisions to be taken should the patient s condition deteriorate. The following issues are included in the ACPA: Care status including plans should carer become unwell Acute Illness/Deterioration: plan should the patient s condition deteriorate Capacity Issues: Guardianship/Power of Attorney Preferred Place of Care Resuscitation Status Explicit Patient consent to share information with other healthcare professionals 2

These plans will be completed and copies kept in the following locations to ensure access by all healthcare professionals who may be involved in the direct care of the patient: Patient s notes in GP Practice Patient s Home Out of Hours Hub Local A&E/PCEC Included in the first phase of the enhanced service will be a requirement for each of these plans to be reviewed approximately every six months or more frequently should the patient s condition change substantially Phase 2: It is recognised through evaluation of the Nairn and other similar anticipatory care projects that whilst contingency planning for those patients at greatest risk of readmission does help to reduce the number of unplanned hospital bed days, there is a requirement to take a more holistic approach to anticipatory care to have greatest benefit. This will involve co-operation and co-ordination of all professionals involved in the care of the patient and will require a greater level of anticipatory care planning, for example falls assessment, completion of single shared assessment, a named individual to regularly review all aspects of the patient s health and social care needs. It is therefore proposed that the next phase of anticipatory care will focus on this more extended anticipatory care plan with full involvement of the extended community care team. It is proposed that a standard format for the extended anticipatory care plan is devised to ensure standardisation across the region and to promote familiarity for all professionals involved in anticipatory care planning regardless of the area. It is proposed that this next phase of anticipatory care planning is piloted in early implementer sites that are already working, or are working towards, this model of an integrated extended community care team. The Review of Nursing in the Community (RoNC) pilot sites are key to testing this model of extended anticipatory care to ensure it is achievable, sustainable and of benefit to the patients. 2.3 Timescales It is proposed that the Enhanced Service SLA for Phase 1 of anticipatory care is circulated to all GP Practices from 1 st July 2009. There is funding identified for each practice to develop the ACPA for the top 1% of their practice population plus care home residents and undertake one formal review of the form prior to the end of the SLA on 31 st March 2010. Indications from other Health Boards who have used Enhanced Services to roll out anticipatory care are that sign up to the SLA is extensive and information on the content of the enhanced service is being discussed within each CHP prior to its distribution. It is proposed that the early implementer sites start to develop the extended anticipatory care plans for the same cohort of patients before 31 March 2010 to allow the model to be tested prior to the continuation of the enhanced service in 2010/2011 where all community care teams will be expected to deliver this extended model of anticipatory care. A meeting to agree the format of the extended anticipatory care plans has been arranged for 11 June 2009. 3

2.4 Evaluation Evaluation of the roll out of anticipatory care will be monitored using the following quantitative performance indicators: Reduction in the number of emergency admissions Reduction in Occupied Bed Day Rates Number of People Being Actively Case/Care Managed (LTCC Core Measure of improvement to be reported on a monthly basis) Number of emergency admissions from care homes (LTCC Core Measure as above) In addition, it is planned to link with the Clinical Effectiveness and PFPI Teams to agree how the patient experience can best be monitored and evaluated. 3 CONDITION MANAGEMENT 3.1 Context Continuing to improve the clinical management of LTCs will reduce complications and the demand on health services (e.g. good diabetic control minimises the risk of eye disease, good control of blood pressure reduces the risk of stroke). Clinical guidelines (shared across primary and secondary care) and evaluation of practice will help. Managed clinical networks, the GP Quality & Outcomes Framework, and the Primary Care Collaborative have already contributed to this agenda. However, clinical guidelines need further development into integrated care pathways, specifying where relevant diagnostics, treatment and rehabilitation are most appropriately delivered. Only then will the kinds of shift in care from acute hospital to community necessary to mange demand be possible. In addition to the specific LTCs highlighted in HEAT target T6 (COPD, CHD, Diabetes and Asthma), the Collaborative will be focusing on Stroke and Rheumatology as conditions which currently impact heavily on acute services. It is also important to note that many (mainly elderly) patients with long term conditions often present with Dementia as a co-morbidity and this must be considered when considering how treatment and rehab is most appropriately delivered. 3.2 Approach The Managed Clinical Networks (MCNs) within Highland are well established, multi disciplinary groups which have the clinical expertise both in primary and secondary care to develop clinical guidelines into fully integrated care pathways. In addition, MCNs have active patient and voluntary organisation involvement ensuring that care pathways take cognisance of other available avenues of care and support for specific conditions. The established MCNs for Stroke, CHD and Respiratory will therefore be tasked with leading this piece of work. The Diabetes MCN will be re-grouped and re-focused to co-ordinate the implementation of the Diabetes Service redesign work in conjunction with the operational units. This redesign will see a shift in the balance of care for diabetes patients from the acute sector to primary care. Gill McVicar is leading on a review of Rheumatology Services across NHS Highland, identifying where redesign is needed to effectively and appropriately shift the balance of care. A 2-day workshop to take this work forward is being arranged. 4

4 SELF MANAGEMENT 4.1 Context The Long Term Condition Alliance Scotland (LTCAS) published a Self Management Strategy in September 2008 entitled Gaun Yersel. The strategy defines self management as a person-centred approach in which the individual is empowered and has ownership over the management of their life and conditions. There are a variety of methods for delivering self management and key to effective delivery of these methods is close working and partnership between health and social care professionals, as well as voluntary organisations and unpaid carers. For the majority of people with long term conditions, self management has been shown to be effective in improving quality of life and promoting appropriate utilisation of services. The amount of time people spend caring for themselves is far greater than the time they are in contact with health professionals. Many commentators suggest however that the NHS, despite its successes, has encouraged a culture in which professionals tend to take control and the public respond by being less involved in their own care than in some other health care systems. As demand increases, and the available workforce decreases in relative terms, the need to maximise self care and self management is evident. This may require a significant culture change for professionals and patients. 4.2 Approach There is evidence from the US, now trialled in England, (Expert Patient Programme) that lay led, generic self management programmes for people with LTCs can reduce demand for services. Pilots of lay led self management programmes have been undertaken in Highland (delivered by Voluntary Organisations) and evaluation completed. NHS Highland is now in discussion with a number of Voluntary Organisations to submit a bid for available funding to continue to deliver, and expand access to, lay led self management programmes across Highland. The programmes will consist of generic patient education modules and condition specific bolt-ons for those patients that require more specialist patient education and self care support. The submission deadline for this proposal is October 2009. In addition, close links are being formed with the Rehabilitation Co-ordinator who is leading on the implementation of the Adult Rehabilitation framework to ensure that self care and self management are integrated into the rehabilitation strategy. 5 CONTRIBUTION TO BOARD OBJECTIVES The objective of the above three work streams is to provide better, faster, more proactive care for people with long term conditions as close to their home as possible and therefore supports the overall Shifting the Balance of Care agenda. The work also supports the strategic direction of other programmes across NHS Highland, in particular the Review of Nursing in the Community, Living and Dying Well and the other National Improvement Programmes (18weeks RTT and Mental Health). In addition, the service improvement work facilitated by the Long Term Conditions Collaborative will help contribute to achieving the following HEAT Targets: T6: To achieve agreed reductions in the rates of hospital admissions and bed days of patients with primary diagnosis of COPD, Asthma, Diabetes or CHD, from 2006/07 to 2010/11 T12: By 2010/11, NHS Boards will reduce the emergency inpatient bed days for people aged 65 and over, by 10% compared with 2004/05 5

T7: Improvement in the quality of healthcare experience T8: Increase the level of older people with complex care needs receiving care at home T10: To support shifting the balance of care, NHS Boards will achieve agreed reductions in the rates of attendance at A&E, between 2007/08 and 2010/11 6 GOVERNANCE IMPLICATIONS Staff Governance: The anticipatory care project is linking in with the work ongoing in the RoNC pilot sites and other workforce development work to ensure that there is the right skill mix, training and support for all staff within the extended community care teams to effectively deliver anticipatory care in the community. Training and education for teaching self management techniques is being developed in conjunction with UHI and Skills for Health to ensure that all staff (health and social care) are provided with the appropriate skills to promote and deliver self management. Patient and Public Involvement: The approach to taking forward anticipatory care is included in the Key PFPI Actions document for 2009/10. Additionally, all patients (and their carers where appropriate) will be fully involved in the completion of the anticipatory care plans and their explicit consent will be required before the plans can be implemented. There is active patient involvement on both the LTC Operational Groups and the Managed Clinical Networks to ensure public engagement in all aspects of the LTC work programme. Clinical Governance: There is currently little evidence on the clinical impact of anticipatory care planning despite a number of literature reviews. Clinical evidence is however available from the Nairn anticipatory care project which indicates that those patients with an anticipatory care plan had fewer admissions to hospitals and fewer hospital bed days once the anticipatory care plan was implemented. All action plans developed for the key work streams have formal evaluation as a standing action to ensure that clinical care is not compromised by service redesign and where possible improved. Financial Impact: It is proposed that 350k of Enhanced Service funding is used to take forward Phase 1 of the anticipatory care enhanced service. Analysis of occupied bed days for this cohort of patients will be analysed in order to quantify any savings from a reduction in bed days. External funding (through the LTCAS) is being sought for the delivery of self management programmes. 6.5 Impact Assessment There has been widespread consultation and involvement from a variety of disciplines and departments who will be either directly or indirectly involved with anticipatory care planning and the other LTC work streams. A formal impact assessment is in the process of being undertaken and will be available by the end of May 2009. Alexa Pilch LTC Programme Manager, NHS Highland 22 May 2009 6