rhona guild: sharing our experiences of using sparra
TRANSCRIPT
Sharing our Experiences of Using SPARRA
Rhona GuildPrimary Care Manager
Angus Community Health Partnership (CHP)
NHS TaysidePopulation
Angus Demographics
• Total population 109,320• Lower than Scottish average population
of working age• Higher life expectancy in both men and
women• 0.8% ethnic minority population• All cause mortality and heart disease
mortality lower that Scottish average and cancer mortality amongst lowest in Scotland.
Demographics (continued)
• Proportion of population hospitalised for alcohol or drug related causes amongst lowest in Scotland
• Significantly lower rate of acute admissions
• Lower levels of homelessness• Lower levels of deprivation
(Source: Scot PHO Health & Wellbeing Profile, 2008)
The Angus Journey
The Angus Journey in Complex Care Management: Step One
•Preliminary studies within general practices in 2006, reviewing complex care pts on basis of Uniquecare criteria
Key Findings from Preliminary Studies
• Patients identified through this process all deemed as complex by professionals involved
• Patients were not high users of unscheduled care
• All patients proactively managed within general practice, with impact of QoF evident
• Recurring themes in those who did have > unscheduled care ( COPD, mental health and/or alcohol issues)
• Issues in entire adult population, not particular to older age groups
• Key issues related to coordination of services between primary and secondary care
Uniquecare Criteria vs SPARRA
• Scottish Patients at Risk of Readmission and Admission identified fewer pts than Uniquecare approach (focussed on >65’s)
• 40% pts on SPARRA list had been identified by initial approach
• 27% pts on SPARRA but not in initial approach had died
• Of remaining 33% pts on SPARRA but not in initial approach, renal issues was a predominant feature. Implications of QoF coding also noted
Uniquecare vs LA Care Management
• Small numbers receiving complex care packages within LA
• 17% pts with complex care packages <65 yrs, 73% >65 years.
• Many had just one long term condition, with an impact on ability to self manage
• Stroke a predominant feature
The Angus Journey: Step 2Early SPARRA
0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%
As
a %
of P
ract
ice
Pop
Abbey HC
Academy M
C
Annat Bank Practice
Arbroath MC
Brechin HC
Parkview
Castlegait Surgery
Edzell HC
Friockheim H
C
Kirriemuir H
C
Lour Rd G
p Practice
Monifieth H
C
Ravensw
ood Surgery
Springfield MC
- East
Springfield MC
- West
Townhead Practice
Total Number of Patients at Risk of Admission
0.00.51.01.52.02.53.03.54.0
Pati
en
t N
um
bers
Abbey H
C
Academ
y M
C
Annat B
ank P
ractic
e
Arb
roath
MC
Bre
chin
HC
Park
vie
w
Castle
gait S
urg
ery
Edzell H
C
Frio
ckheim
HC
Kirrie
muir H
C
Lour R
d G
p P
ractic
e
Monifie
th H
C
Ravensw
ood S
urg
ery
Sprin
gfie
ld M
C - E
ast
Sprin
gfie
ld M
C - W
est
Tow
nhead P
ractic
e
Patients with 70-90% Risk of AdmissionOther
Injuries
Ill Defined
Mental Health
Digestive
COPD
Resp
Circulatory
Heart Disease
Cancer
The Angus Journey: Step 3Gold Standards Framework for LTC’s
in General Practice•The Gold Standards Framework (GSF) is a ‘systematic evidence based approach to optimising the care for patients nearing the end of life in the community’.
•The focus of GSF is to improve care in the community by optimising the local primary care team’s provision, so that more patients are enabled to live and die where they choose, and un-needed hospital admissions are avoided.
3 processes of GSF include:
• Identification of patients in need of palliative/supportive care
• Assessment of needs, symptoms, preferences etc
• Care planning and delivery.
5 GSF Goals:• Good symptom control.• Patients enabled to live and die well in
their place of choice.• Better advanced care, planning,
information, less fear, fewer crisis/hospital admissions.
• Well supported and informed carers.• Staff confidence, communication and co-
working.
Aims of GSF Project for LTC’s•To explore the impact introduction of the Gold Standards Framework (GSF) in the management of complex Long Term Conditions Management, within primary care, had on patient outcomes and staff satisfaction
Pilot Details
• Based in Academy Medical Centre, Forfar
• Large teaching practice• Practice population 10990• 81% being under the age of 65 • 19% over the age of 65.• Multi-agency participation• 2008-9
‘Top Ten’: Identification
• Identified through SPARRA and Tayside Predictive Tool
Or• Recommendation of patients by core team
member and approval by others• Any adult eligible for inclusion and the
project did not focus exclusively on any given areas of priority from a disease, multi-disease or age perspective
Project Plan
• Education of staff re aims of complex care management, & GSF
• Core list of ‘top ten’ agreed by core team• Inclusion in supportive care register• Monthly meets aimed to improve the flow of
information, advance care planning and measurement/audit of outcomes
• Shared care planning
Our Top Ten!Patient No
Age Long Term Conditions(List all)
How Identified?Sparra/PEONY/Team/Other
Services at Outset of Projecteg GP, DN
New services or changes to care as a result of pilot
Emergency Care Contacts 6/12 pre-pilot
Emergency Care Contacts 6/12 during pilot
Eg 85 CHDDiabetes
District NurseNot on SPARRA
DNGP
Care management
10 5
1 69 DIABETICHYPERTENSION
PN PN 3 0
2 61 CHDMS
CM CM+DN 0 0 and no GP visits
3 79 COPDCKD
SPARRA PRACTICE 2 2
4 68 COPDCKD
DN ALL DIED DIED DIED
5 74 DIABETICHYPERTENSIONCOPD
DN DN + CM 2 2
6 83 HYPERTENSIONCHDCOPDCKD
DN DN 0 0 and 0 OOH callouts
Patient No
Age
Long Term Conditions(List all)
How Identified?Sparra/PEONY/Team/Other
Services at Outset of Projecteg GP, DN
New services or changes to care as a result of pilot
Emergency Care Contacts 6/12 pre-pilot
Emergency Care Contacts 6/12 during pilot
7 59 DIABETICCHDCKD
DN DN PN 0 0 and 0 OOH callouts
8 82 HYPERTENSIONCHD
CM CM + DN 1 0 and 0 OOH callouts
9 67 HYPERTENSIONMS
CM CM 3 0
10 78 CHD SPARRA CM + PRACTICE
2 0 and 0 OOH callouts
TOTALS 13 4
Q1. In your opinion, has this project improved communication between the professionals involved
in the care of the patients included?
100%
0%0%
YesNo DNA Q2. Has your understanding of the roles
performed by other professionals involved in the project improved as a result of this project?
72%
14%
14%YesNo DNA
Q11. Do you feel that this project has been a success?
100%
0%0%
YesNo DNA
Staff Views on Most Effective Means of Pt Identification
• ‘Case discussion. SPARRA chose patients that were deceased or had very little input from both social work and health’
• ‘I decided to use the SPARRA data as a tool for identifying my patient. This proved ineffective due to its basis on retrospective data and in fact my patient had no admissions or GP contacts during the duration of the pilot despite multiple co-morbidities and numerous preceding issues, which required MDT work.’
• ‘SPARRA search and individual proposal of suitable patients. Some patients we felt who would be suitable for inclusion did not appear on the electronic search’
• ‘Individual/team knowledge’• ‘Best “mechanism” for patient identification was without doubt
the DNs!’
The Angus Journey: Step 4
• Cross reference of SPARRA lists with existing care/case management services, to aid dissemination of information/use of data
• General Practice : Quality & Outcomes Framework +
• COPD Anticipatory Care Project
COPD Anticipatory Care ProjectAll COPD patients registered with Montrose practice with COPD related admission during period of pilot
All COPD patients registered with Montrose practice with COPD identified by SPARRA as being at risk of recurrent admission
Clinical agreement of suitability of any other COPD patient registered with Montrose practice
Agreement of inclusion of patient in anticipatory care project by clinicians with links with Palliative Care DES and advice from other agencies where appropriate.(Maximum caseload to be agreed, approx 15 patients at any given time)
1. Holistic assessment by COPD nurses offered to all patients identified through SPARRA or team, who have not had a COPD assessment by housebound service within last 6 months.
2. In addition to normal care, all COPD related discharges will receive a joint assessment visit by DN and COPD housebound nurse on the next working day after discharge (even where ESD in place).
1Care plans to be developed, with a focus on patient goal setting and self management education, using the BLF COPD Self-Management Plan in all cases, and Palliative Care DES information if appropriate.
2 Anticipatory care planning for all patients, including recording of information in OOH systems.
3 Urgent referral to pulmonary rehabilitation if appropriate.4 Standardised community and COPD housebound nursing documentation to be used.5 Ongoing implementation of care plan, with minimum of 3/12 review.
Criteria Pt1* Pt2 Pt3* Pt4* Pt5*
Smoking status Smoker
Smoker
Smoker
Immunisation status
Assessment of MRC dyspnoea score
3 3 2 2 3
Medication review
Inhaler technique
Education
Self-management BLF booklet
BLF booklet
BLF booklet
BLF booklet
BLF booklet
Co-morbidities
Assessment of psychological co-morbidity
Anticipatory care planning
on Taycare
on Taycare
on Taycare
on Taycare
on Taycare
Others TaxicardRescue medsExercise advice
Referral for anxiety mgtNew devicesReferral to pulmonary rehab
OT referralExercises
Meds changesDevices changesRescue medsCMT referral
Smoking cessation adviceNew devicesMeds changesExercise on referralReferral to pulmonary rehab
Status at end of project
On DN service books prior to project. Care ongoing
Admitted onto DN caseload & COPDHousebound service
Admitted onto DN caseload & COPDHousebound service
Discharged Discharged back to PN
Pt6* Pt7 Pt8* Pt9
Smoking status Smoker
Immunisation Status
Assessment of MRC Dyspnoea Score
4/5 3 5 4
Medication Review
Inhaler Technique
Education
Self Management BLF booklet
BLF booklet
BLF booklet
BLF booklet
Co-morbidities
Assessment of Psychological Co-morbidity
Anticipatory Care Planning
on Taycare
on Taycare
on Taycare
on Taycare
Others Rescue medsContinence assessment
Rescue medsFlu vacOral thrush identified and tx, and oral hygiene taughtCommenced antidepressantsReliant of nebulisersTaught re use of aerochamberPortable O2 arranged for holidays
Meds changedRescue medsInhaler techniqueDental referral
Flu vacReferral to pulmonary rehabilitationRescue medsReferral to pulmonary rehab
Status at End of Project On DN service books prior to project. Care ongoing
Discharged back to PN On DN service books prior to project. Care ongoing
Admitted onto DN caseload & COPDHousebound service
General Observations Regarding SPARRA
•Accuracy of data sources•1/4rly report limiting•? Finding patients too late?•? Disadvantaged by lack of GP data feed?•Variable use of SPARRA data
To effectively implement and evaluate systems for complex care, we need a tool to effectively identify those who we can effectively make a quantitative as well as qualitative impact
Next??•Virtual wards•QoF+•? Enhanced service within general practice