Complex Care Management In Practice

1. Complex Care Management In Practice Dunblane Tuesday 6th November 2007

2. Pre 2003 • 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

3. 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

4. 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

5. Co-prevalence

6. Comorbidity(the simultaneous presence of multiple chronic conditions)

7. During 2004 • 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

8. Complex Care Nurse Specialist Role Managing co-mobidity Proactive Recall and Team Management Delivering Patient Centred Scheduled Care efficiently by the Primary Care Team

9. 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)

10. 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 Riverview Medical Centre

11. Clinical Care Follow Up Plan • 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

12. Clinical Care Follow Up Plan- upper page

13. Clinical Care Follow Up Plan- lower page

14. Complex Care Nurse Specialist Tasks • 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

15. Missed Deadlines Report

16. The Team • 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

17. Plan Implementation - Community • 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

18. WORKING TOGETHERComplex Care Nurse Specialist Role in scheduled primary care

19. Benefits • 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

20. Constraints • Time • IT programme needs further development • Barrier to referrals for Nursing staff-although slowly resolving.

21. Finally:- • If you have been…… • Thanks for Listening