dr judith carrier, senior lecturer/co-director postgraduate studies, cardiff university

Dr Judith Carrier Cardiff University 2015

Managing Long-term

conditions and Chronic

Illness in Primary Care

A guide to good practice (2nd ed.)

Aim

To discuss effective management of long-

term conditions and the importance of

systematic and evidence-based care in

primary care which takes account of the

expert patient.


The book

1. Social and political background

2. Physical, psychological and psychosocial impact of living with an LTC and

social influences on health

3. Case management and disease-specific care management

4. Importance of self-management

5. Health behaviour change and motivational interviewing

6. How to identify a person with a LTC

7. Effective management of people with a LTC

8. Evidence-based practice

9. Case scenarios

10. Nutritional and medication management

11. Afterword

(N.B. All author royalties donated to Bwindi Community Hospital, Uganda and the Gorilla

Organisation)



This is what Ruby the spaniel thought of it!

So what’s the problem?

Increasing numbers/stretched resources

Victims of our own success (increased life expectancy

has resulted in LTCs emerging as the dominant

challenge to health and care systems)

Numbers continue to rise due to an ageing population

and certain lifestyle choices that people make.

Geographical variation (nationally and internationally)


So what’s the problem?

Patient surveys persistently show that half of

patients feel they aren’t involved in decisions

about their care (Eaton 2012)

Living with an LTC can have a physical,

psychological and psychosocial impact on

individuals.



What systems are in place to help?

Service frameworks

Local and national policy drivers (e.g. NHS

Outcomes Framework and the House of Care

Model)

GMS contract and QOF

Health informatics and Telehealth

International/national models of care/service

delivery models e.g. Chronic Care Model (Wagner

1998, 2011)

Key principles

Organisation, culture and mechanisms of

delivery

Empowerment and person centred care

Working in partnership

Mobilising community resources

Preventative policies


House of Care Model(NHS England 2014)


So what can we do?

1. Assess what level of care is required

2. Provide structured care that is pro-active,

holistic and preventative

3. Utilise multi-disciplinary teams effectively


Assessing the level of care

required (Kaiser Pyramid)


Assessing the level of care

required

Supported self-care: Collaboratively helping individuals and their carers to

develop the knowledge, skills and confidence to care for themselves and

their condition effectively.

Disease specific care management

Case management

(DH 2005)


Supported self-care-what should we

be doing in primary care?

Implementation gap between policy aspirations

and delivery of self-management support in

primary care

Self-management hindered by:

1. Task driven nature of nurses’ routines

2. Lack of motivation by nurses to engage with

self management activities (Kennedy et al 2013)


Three themes that shape peoples’

responses to self-management

The different ways in which people receive

their diagnosis

The fact that different people have different

responses

The fact that peoples’ ability to self-manage

changes over time(Corben and Rosen 2005)


Supporting self-management

effectively-three themes

Good relationships between health professionals

and patients

The need for patients to have clear information

about their condition and guidance on how to

access it

The need for flexibility in service provision(Corben and Rosen 2005)


Self-care interventions-what’s

effective?

All round interventions that include continuing education,

physician feedback and patient oriented interventions

(Renders et al 2011)

Problem-solving interventions (Fitzpatrick et al 2012)

Action plans as part of a multi-faceted self management

programme (Walters et al 2010)

Group education or individual education combined with

other self-management strategies (de Silva 2011)



Self-care interventions-what’s

effective?

Patent practitioner encounter should encompass:

Sound information at diagnosis

Comprehensive, paced, user friendly information

Allowing patients to discuss their own ideas about self-care actions, including life-style management

Allowing patients to feel listened too and have time to ask questions

Time, resources, open access, seeing the same doctor, appropriate referral

Orientating consultations towards skills and competencies needed for self care

Goal setting and care planning(Rees and Williams 2009)

Seven characteristics of a

‘good’ self manager

The capacity of an individual to:

1. Have knowledge of their condition

2. Follow a treatment plan agreed with their health professional

3. Actively share in decision making with health professionals

4. Monitor and manage signs and symptoms of their condition

5. Manage the impact of the condition on their physical, emotional and

social life

6. Adopt lifestyles that promote health

7. Have confidence, access and the ability to use support services

(Flinders University 2014)


Disease specific care

management

Providing people who have complex single

need or multiple conditions with

responsive, specialist services using multi-

disciplinary teams and disease-specific

protocols and pathways (DH 2005)


Systematic care approaches

The 3 Rs-registration/recall/review

Develop evidence-based care pathways and

protocols that incorporate teamwork and

clear referral criteria

Monitor and evaluate service provision using

clinical audit and/or quality improvement

processes

Use telehealth and telecare



Steps to implement case

management

Requires the identification of the very high

intensity users of unplanned secondary

care. Care for these patients is to be

managed using a community matron or

other professional using a case

management approach, to anticipate, co-

ordinate and join up health and social

care. (DH 2005)

Steps to implement case

management

Identify vulnerable patients (agree on criteria)

Develop the case manager role

Carry out thorough assessments-care

planning

Co-ordinate care and services


Effective teams:

Include the patient, carer or representative as an essential member

of the PHC team.

Have a common agreed purpose

Agree set objectives and monitor and publicise progress

Understand role boundaries

Acknowledge skills of others

Communicate effectively

Select a leader for leadership skills

Promote teamwork initiatives and evidence based practice

(adapted from Royal Pharmaceutical society/BMA 2000)


Utilise multi-disciplinary teams in

primary care


Work closely together-you can’t do this on your own!

Key areas not to forget

Behaviour change techniques (e.g.

motivational interviewing)

Nutritional management

Medicines management



Drawing on evidence to support

practice-some resources

TRIP database- https://www.tripdatabase.com/

NICE-Clinical Knowledge Summaries- http://cks.nice.org.uk/

NICE guidelines- http://www.nice.org.uk/guidance/conditions-and-diseases

SIGN- http://www.sign.ac.uk/

Clinical Evidence- http://clinicalevidence.bmj.com/x/index.html

Cochrane Collaboration- http://www.cochranelibrary.com/

Campbell Collaboration- http://www.campbellcollaboration.org/

Joanna Briggs Institute- http://joannabriggs.org/

University of York Centre for Reviews and Dissemination-

https://www.york.ac.uk/crd/

http://cks.nice.org.uk/

http://joannabriggs.org/

And finally

Remember that you are not alone, healthcare

involves teamwork

Respect the knowledge of others including

your patients, their families and carers

Respect your patients’ wishes, the decision

regarding their care is ultimately theirs, we

can but advise and support



Thanks for listeningDiolch yn fawr

dr judith carrier, senior lecturer/co-director postgraduate studies, cardiff university

Healthcare