Long Term Conditions Predictive Case Finding Tool Conference

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Long Term Conditions - Predictive Case Finding
Tool Conference

• 27th October 2005
• Novotel London West, Hammersmith

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Virtual Community Wards

• Dr. Geraint Lewis MA MRCP
• Public Health Department

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Census data
Social services data
Hospital episode data
GP practice data
Pharmacy data
Predictive Modelling
Intervention
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Intervention
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Intervention
Improved quality of life
Better disease control
Healthier Patients
Fewer unplanned hospital admissions
Net financial benefit
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• Hospital Wards
• Multidisciplinary Team
• Complex
• Infrastructure
• Human Resources
• Timetable
• Clinicians patients have an intuitive
  understanding of how they work

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• Community Wards
• Mimic hospital ward
• Patients cared for in their own homes
• Clinicians patients have an intuitive
  understanding of how they will work

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• Community Wards
• Patients case managed by multidisciplinary team
• Ward Team headed by Community Matron
• Named case manager equivalent to Named Nurse on
  a hospital ward

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10 Croydon Community Wards

• Croydon population 300,000
• Ward population
• 300,000 10
• 30,000
• ? 15 GPs patients
• 1 commissioning group of GP practices

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3 Pilot Community Wards

• 3 pilot sites initially
• Pilots to be rigorously evaluated using a
  Randomised Controlled Trial
• If successful then to be rolled-out across the
  borough

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Virtual Ward A
Virtual Ward B

• Specialist Staff 
• Specialist nurses
• Asthma
• Continence
• Heart Failure
• etc.
• Community mental health team
• Palliative care team
• Alcohol service

GP Practice 1
Community Ward A Community Matron Nursing
complement Ward Administrator Pharmacist Social
Worker Physiotherapist Occupational
Therapist Voluntary Sector Helper Visiting
Physician    
GP Practice 2
GP Practice 3
GP Practice 4
Community Ward B Community Matron Nursing
complement Ward Administrator Pharmacist Social
Worker Physiotherapist Occupational Therapist
Voluntary Sector Helper Visiting Physician  
GP Practice 5
GP Practice 6
GP Practice 7
GP Practice 8
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Specialist Staff Visit several wards
Analogous to diabetic nurse specialist who
visits several hospital wards
Community Ward A    

Community Ward B    



Community Ward C    





Community Ward D    


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Medical Input

• Patients own GP provides medical advice
• Formal links
• Practice nurses
• Telephone system bypass number
• Long-term continuity of care

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Medical Input

• Weekly ward round by visiting doctor for most
  complex patients
• Consultant General Physician
• Consultant in Medicine for the Elderly
• GP with special interest in Long Term Conditions
• Visiting doctors may reserve dedicated
  appointments in their clinics for Community Ward
  patients

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Expert Patients Programme
Virtual Ward
Outpatients
HDU
Daily review
Weekly review
Monthly review
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100 patients per ward
Virtual Ward 35 Patients
Outpatients 60 Patients
HDU 5 Patients
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(35 ? 5)
(60 ? 20)
5 7 3 15 patients for discussion each day
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Discharge from Ward

• After patient has spent several months in
  Outpatients
• Patient is discharged back to GP practice
• GP practices asked to conduct quarterly (rather
  than annual) reviews on these patients
• Closer monitoring
• Richer data for re-analysis by predictive
  software ? positive feedback loop

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Daily Timetable

• Multidisciplinary ward round
• Nursing ward round
• Ward-work
• Evening hand-over

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List of patients
Predictive Algorithm
Does patient live in a pilot area?
No
Standard care
Yes
Does patient consent to participating in the
trial?
No
Yes
Patient enrolled into trial
Randomization
Community Ward
Standard Care
After 6 months analyse compare two groups
 
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Financial Perspectives

• Net financial cost / benefit to be assessed from
  the viewpoints of
• PCT
• Acute Trust
• Social Services

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Commissioning

• Community wards ideal size for a small group of
  GP practices to commission under Practice Based
  Commissioning

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geraint.lewis_at_nhs.net
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