commissioning care pathways for chronic diseases
DESCRIPTION
Commissioning Care Pathways for Chronic Diseases / Long Term Conditions This was a presentation I made recently for a conference on Long Term Conditions which was unfortunately cancelled, but I had already written and researched the slides so wanted to put them up for people to see! Explains how to commission effective services to deal with patients suffering from long-term (chronic) conditionsTRANSCRIPT
Commissioning Care Pathways
for Chronic Diseases
James GuptaMedical Student | University of Leeds
QIPP Lead | Windermere Medical Centre
Overview & Aims
What are pathways, when do we use them and why do we need them?
Developing a pathway-based approach to COPD commissioning
How can we measure the impact of pathways on patient care?
Commissioning for ‘whole person’ care
Our experience(overview of the StHealth COPD project)
© James Gupta 2012 | [email protected]
What is a ‘Pathway’?
© James Gupta 2012 | [email protected]
© James Gupta 2012 | [email protected]
Post-op complications fell 33%Inpatient deaths by 40%
What is a ‘Pathway’?
“Integrated Care Pathways (ICPs) provide a template for multi-disciplinary care that is evidence-based and co-ordinated.” – Clinical Governance, NHS Scotland 1
“An integrated care pathway (ICP) is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.” – Oxford University Medicine 2
“A care pathway is anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency 3
1) NHS Scotland Clinical Governance, What are integrated care pathways, http://www.clinicalgovernance.scot.nhs.uk/section2/pathways.asp2) Bandolier, Integrated care pathway, http://www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html
3) Welsh Assembly Government, Innovations in care 2003.
© James Gupta 2012 | [email protected]
What is a ‘Pathway’?
“A template for multidisciplinary care that is evidence-based and coordinated.” – Clinical Governance, NHS Scotland
“A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.”
– Oxford University Medicine“Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency
Multidisciplinary
© James Gupta 2012 | [email protected]
What is a ‘Pathway’?
“A template for multi-disciplinary care that is evidence-based and coordinated.” – Clinical Governance, NHS Scotland
“A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.” – Oxford University Medicine“Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency
Multidisciplinary Evidence-based
© James Gupta 2012 | [email protected]
What is a ‘Pathway’?
“A template for multi-disciplinary care that is evidence-based and coordinated.” – Clinical Governance, NHS Scotland
“A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.”
– Oxford University Medicine“Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency
Multidisciplinary Evidence-based Anticipated
© James Gupta 2012 | [email protected]
What is a ‘Pathway’?
“A template for multi-disciplinary care that is evidence-based and coordinated.” – Clinical Governance, NHS Scotland
“A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.”
– Oxford University Medicine“Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency
Multidisciplinary Evidence-based Anticipated
Local & Specific
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Available from sthealth.org.uk/copd_resources.htm
Why do we need pathways?
Time & budget restraints
Patients receiving care from different professionals
Need to make care as efficient as possible and reduce variation
Every patient is unique, but key features will be seen repeatedly
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When do we use pathways?
We all use pathways, every day
Structured decision-making process based on knowledge (evidence) and experience
© James Gupta 2012 | [email protected]
What are the benefits of using pathways?
Patients receive care that is not only more consistent, but also of a higher standard and more up to date with the latest evidence
Clinicians feel more confident and can get more done in less time
Resources are used more appropriately
Emergency / non-elective admissions can be reduced
Rotter et al Cochrane Review 2010
1) Rotter et al, Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006632. DOI: 10.1002/14651858.CD006632.pub2.
2) Campbell H, Hotchkiss R, Bradshaw N, Porteous M, Integrated care pathways. BMJ 1998, 316(7125):133-7.3) Lowe C, Care pathways: have they a place in ‘the new National Health Service’? J Nurs Manag 1998, 6(5):303-6.
© James Gupta 2012 | [email protected]
Developing a Pathway Approach to COPD Commissioning Multidisciplinary
Chest physicians GPs Practice nurses COPD / community nurses Practice managers Pharmacists Respiratory physiotherapists Smoking cessation advisers Spirometry technicians
Committed
Lead: clinical and managerial experience
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Developing a Pathway Approach to COPD Commissioning Assess your current patient
journey: Time wasters Black holes Bottlenecks
Plan a new patient journey THINK OUTSIDE THE BOX!
Listen to the views of ALL your MDT equally regardless of ‘seniority’ or qualifications. Expect some ‘culture shock’ between primary and secondary care professionals, encourage it!
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Primary/Secondary Care Conflict
Peter – Consultant chest physician Wendy – Practice nurse
© James Gupta 2012 | [email protected]
Primary/Secondary Care Conflict
Peter –chest physician Wendy – Practice nurse
“Patients should have full post-bronchodilator spirometry performed by an accredited technician every time they come for a review – other measures of lung function simply aren’t accurate enough”
Liz – Pathway lead
“We’re really busy in primary care so don’t
always have time to do spirometry – often
we can see how a patient is getting on
by asking them questions, their
general appearance, peak flow etc”
© James Gupta 2012 | [email protected]
Developing a Pathway Approach to COPD Commissioning
The hardest part
Simply distributing the final pathway will not work
Has to be done alongside structured clinician education
Advertise the mutual benefit: Improve patient care AND Make your job easier!
Resistance to change
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Measuring the impact of pathways on patient care
QOF Flu jab L12M FEV1 L15M MRC score L15M
Not acceptable!!
Many ways to measure REAL changes in the patient experience
Identify them early!
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Commissioning Quality Markers: Measuring the impact of pathways on patient care
Must ultimately focus on REAL clinical outcomes
May take many years to see full benefit of these
Surrogate endpoints in meantime
Cost reductions / QIPP
Primary Endpoints
Surrogate Endpoints
Process Markers
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Commissioning Quality Markers
Should focus on real outcomes where possible Admissions /
Exacerbations Quality of life
(King George, PHQ9) Smoking quit rates
Costs Referrals Prescribing
% referred for pulmonary rehab
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Commissioning for Whole-Person Care COPD is being increasingly seen as a systemic disease with
associated co-morbidities: Depression Heart Failure Osteoporosis (corticosteroid-induced) Hypertension Cardiovascular disease Lung cancer Bronchiectasis
Yet current care-pathways do not operate like this – definitely something to bear in mind
Good model: diabetes – common co-morbidities / complications are treated and screened for under one (relatively) cohesive model
1) Barnes PJ, Celli Br, Systemic manifestations and comorbidities of COPD. Eur Respir J 2009, 33(5);1165-85
© James Gupta 2012 | [email protected]
Case Study: StHealth COPD Project
Joint working initiative with GlaxoSmithKline(DH toolkit)
StHealth Practice Based Commissioning Consortium (now Shadow CCG)
Focused on enhanced management AND early detection of COPD
Pathway-based
Led to reduction in hospital admissions and
prescribing costs, increase in patient satisfaction, quality of
reviews,
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Key Pillars
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UK/MARK/0023/10 – April 2010© James Gupta 2012 | [email protected]
QIPP
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Summary Pathways are multidisciplinary, evidence-based, local &
specific
Take best available evidence and adapt it to local needs & provision
Can increase standard of care for chronic conditions
Reduce costs, admissions/bed days and improve quality of life
Need to identify commissioning quality markers
© James Gupta 2012 | [email protected]