Lorraine Hewitt Community Advance Nurse Practitioner Uwch Nyrs Ymarferydd

1. Lorraine Hewitt Community Advance Nurse Practitioner Uwch Nyrs Ymarferydd District Nursing Service Chronic Care Management Provision

2. Aims • To understand the role of the Community Advanced Nurse Practitioner (CANP) • To understand the need for the provision • To highlight development of infrastructure within the practice field • To highlight problems encountered in the practice field

3. Introduction • In Wales the older population is expected to grow by 11% by 2020 • Dependency increases with age. • 75% aged 75+ have at least one chronic condition • 78% of health service expenditure is connected to chronic conditions.

4. What is a Chronic Condition? • Definitions Chronic disease, lifelong diseases/conditions, long term diseases/conditions or limiting long term conditions • Chronic conditions can not be cured only controlled. • They are life-long and limiting in terms of quality of life • They require self managing skills and ongoing care.

5. The need for radical redesign for health and social care services A robust and evidence based approach to disseminating best practice and improving system performance The need to develop capacity outside acute hospital settings Greater public and patient involvement Stronger performance management systems Wanless (2002) Recommendations

6. Welsh Chronic Condition Model This Model and Framework sets out the broad approach to ensure the right service are provided in the right place at the right time and meets local needs more effectively (WAG 2008) • Proactive, planned and managed approach, identifying and addressing patients’ needs across the care pathway. • Focused on the needs of individuals and where possible to prevent or delay chronic conditions arising.

7. Level 4 Proactive and Planned Management of ChronicConditions Level 3 High Risk Management • Information and Public and Service and Monitor and • Data Analysis Patient Needs SupportEvaluate Level 2 Population management Service example…. QUALITY ASSESS High Risk Patient Data – Case Management Case Managed Services social and other care services Level 1 Primary Prevention & Health Promotion Performance Management Network Based Service Social/ voluntary outreach Clinics/care GPWSI /Specialist Nurse, Specialist Service Secondary/ Social Care Information Trends Evaluation Public/Patient Consultation Practice Base Service Self care and EPP Annual review, Lifestyle support Primary / Social Care Data, QOF Patient Data Health Improvement- Self care, lifestyle support Target intervention Population Data

8. Proactive and Planned Management of ChronicConditions • Level 4 initially targeted through hospital discharge monitoring however CANP’s found either patients very ill or already on revolving door and difficulty breaking therefore now targeting high level 3 prior to acute hospital admission but high users of unplanned primary care

9. Community Advanced Nurse Practitioner Chronic Care Is a Registered Autonomous Nurse Practitioner working in the generic primary care field with an additional advanced clinical skills qualification (Masters level) which enables them to assess patient’s and carers’ with in their own homes to plan appropriate service in order to optimise care options and improve patients quality of life.

10. Aim of Community ANP Role • To co-ordinate and deliver skilled evidence based nursing care sustaining patients within their own homes • To promote and teach self care wherever possible leading to personal independence. • To facilitate safe and effective discharges from hospitals and prevention of inappropriate admissions by improving interface between primary and secondary care • Reduce unplanned GP and OOH care • Improve concordance with medication

11. Knowledge & Skills Framework of Post • MSc Advanced Clinical Practice • Take a complex History • Perform a Physical Examination: Inspect, Palpate, Percussion, Auscultation • Form Differential Diagnosis • Form a clinical management plan • Order and respond to appropriate Investigations • Independent Prescriber

12. Integration • Operational policy • Advanced Nurse Practitioner Working arrangements • Chronic Conditions – Patient Survey • Database of interventions and outcomes of care • Integrating through educational programs of existing District Nursing staff

13. District Nurses team members General Practice Case Finding Hospital – Acute & Community Residential Home Family members Social Services Specialist Nurses Self Hospice Occupational Therapy Physiotherapy Referrals

14. Following Referral the patient can expect: • A personalised assessment • Acute intervention to stabilize condition • Education package to improve out comes and self care • Empowerment

15. Effective care management leads to: • Facilitating safe and timely discharges • Preventing breakdown of care packages • Reducing readmission rates • Preventing ill health/accidents which may precipitate admission or moving to residential/nursing care setting • Increase patient’s independence

16. Types of activities undertaken • Cardiac & COPD are the main chronic disease problems seen with Co morbidities • Main problems identified in practice supports others findings of non compliance to medication due to multiple factors e.g. out of date medication, equipment, poor knowledge of medication, interactions and lack of motivation, improvement in health

17. Developing documentation • Advanced nursing assessment forms Essential to incorporate medical domain Used in conjunction with Unified assessment  Documentation is an important characteristic of the CANP’s role that is shared between professionals as a communication tool that can be integrated across the spectrums of care promoting continuity of care.

18. ADVANCED NURSE PRACTITIONER ASSESSMENT • Name & address: NHS no: • D no: DOB: • Telephone GP Name & address: • Presenting Complaint: • History of presenting Complaint: • Patient perspective/expectations/motivation • Assessed by: Date: • Medication on admission • to caseload Allergies and drug reactions /interactions Personal History Smoking/Alcohol consumptionFamily HistorySocial History Past medical and nursing historyGeneral Appearance, Observations

19. CARDIOVASCULAR SYSTEM Cardiac System GASTRONINTESTINAL Assessed by: Date: NEUROLOGICAL SYSTEM Assessed by: Date: Ears nose and Throat: (Ear Ache, Dysphagia, nasal obstruction, sore throat) Date:

20. Assessed by: Date: CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM Assessed by: Date: NEUROLOGICAL SYSTEM Assessed by: Date: Ears nose and Throat: (Ear Ache, Dysphagia, nasal obstruction, sore throat) Assessed by: Date:

21. NEUROLOGICAL SYSTEM

22. EAR NOSE AND THROAT

23. ADVANCED NURSE PRACTITIONER ASSESSMENT Presence of Other Breath Sounds (crackles, inspiratory wheeze, expiratory wheeze, pleural rub) Left Right Left Right Presenting Complaint: • Diagnosis (Main Problems) • Initial Management • Investigations • Include Normal base line for individual and new investigations • HB K+ ECG • WBC Urea Chest X ray • Platelets Creatinine CT scan • CRP Glucose Other • Na Ca+ C enzymes • TFT LFT CBG • Wt. Ht. BMI Urine Assessed by: Date: GASTRONINTESTINAL Assessed by: Date: NEUROLOGICAL SYSTEM Assessed by: Date: Ears nose and Throat: (Ear Ache, Dysphagia, nasal obstruction, sore throat) Chest X ray Platelets Creatinine CT scan CRP Glucose Other Na Ca+ C enzymes TFT LFT CBG Wt. Ht. BMI Urine Assessed by: Date:

24. Medicine Management sheet • Pharmacist model adapted to our field of work • INP communication sheet Used to inform other members of the MDT of drug changes and prescriptions if unable to enter on computer records

25.  Observation forms • Observation forms are used to compare episodes of care, track and assist recognition patterns and cues to instruct and shape decisions. Percussion: Right Normal Flat Dull Resonant Hyper resonant Tactile/vocal Fremitus normal Y/N Left Normal Flat Dull Resonant Hyper resonant Tactile/vocal Fremitus normal Y/N

26. Presence of Other Breath Sounds (crackles, inspiratory wheeze, expiratory wheeze, pleural rub) Auscultation: Equal Right Normal/ Reduced/Bronchial Breathing/ Silent Left Normal/ Reduced/Bronchial Breathing/ Silent Observations B/P Pulse Resp Temp SPO² Weight colour sputum Date& Signature

27. Patient Problems /Focus sheet • Based on care of the dying documentation • It was designed to use quickly to identify problems • Aids recognition

28. Patient Problems /Focus sheet • Goal 1: Educate Patient self management of their long term condition • Patients attitudes and anxieties regarding their long term conditions are addressed • Information on coping strategies provided • Educate Patient on disease management • Provide information relating to Health Promotion • Educate Patient on breathing techniques • Patient performance scoring • 0=Fully active 1= Restricted in physical strenuous activity 2= Ambulatory, self caring, unable to work 3= Capable of limited self care 4 = Unable to carry out self care

29. Goal 2: Management of long term conditions and related symptoms • Patient able to cough and self expectorate • Referral to specialist services as appropriate • Educate Patient to monitor chest pain • Severity of pain recorded on pain assessment tool • Educate Patient on oedema management • Educate Patient on complications relating to diabetes • Encourage uptake of annual health checks • No identified changes to sleep pattern/Mood

30. Educate Patient/carer on correct use of medications Educate Patient/carer on correct use of GTN spray Medication reviewed in last 6 months Goal 3: Medicines Management

31. Goal 4: Patient is supported to remain in a community setting • No deterioration in patient’s nutritional status identified • Personal and domestic needs met • No deterioration in patient’s skin integrity identified • Patient understands need for rest and relaxation during times of exacerbation of disease process • No deterioration in patient’s mobility status identified • No changes identified to patients normal elimination pattern • No changes identified to by patients carer • Observations with in normal limits for individual patient

32. Advanced Nurse Practitioner Referral Form Episode of care summary Transfer of care summary  Patient information sheet Multidisciplinary communication

33. Pit Falls • Poor understanding of role • Resistance to change from both professionals and the public • Ownership • Name Case manager

34. Patient Survey • Findings • Average Age 70 • Minimum Age 21 • Maximum Age 88 • 48% N=29 Felt that their understanding of their health had improved a lot since seeing the Community Case Manager

35. 66% reported improved changes to their quality of life? 76% reported change in how their healthcare was organised? 93% claiming contact benefited them

36. Shaping the future Service Development • Expanding Service training Advanced Nurse Practitioners • Associate Practitioner • Clerical support • Increase Knowledge and Skill within the District Nurse Service

37. Thank you very much for listening • Any questions??