Complex Care Management In Practice

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Complex Care Management In Practice

• Dunblane
• Tuesday 6th November 2007

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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

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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

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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

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Co-prevalence
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Comorbidity(the simultaneous presence of
multiple chronic conditions)
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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

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Complex Care Nurse Specialist Role

• Managing co-mobidity
• Proactive Recall and Team Management
• Delivering Patient Centred Scheduled Care
  efficiently by the Primary Care Team

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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)

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Riverview Medical Centre

• 3 GPs
• 2 GP Registrars
• 1 FY2
• 1 Practice Nurse
• 1 Health Care Assistant
• 1 Phlebotomist
• 2 District Nurses
• 2 Health Visitors

• Medical Staff
• Practice Employed
• Health Board Employed

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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

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Clinical Care Follow Up Plan- upper page
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Clinical Care Follow Up Plan- lower page
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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

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Missed Deadlines Report
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The Team

• DRM updated by Drs PN and HCA during
  consultations
• Clinical Care Plans generated and given to DNs,
  Phlebotomist and HVs as appropriate
• Important to know the nursing team and their
  level of skills and competences
• Good rapport and communication skills

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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

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WORKING TOGETHERComplex Care Nurse Specialist
Role in scheduled primary care
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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/ Gps and staff
• For PN / Surgery
• Less time spent on recall
• Improved working relationships -teamwork
• learning needs Identified
• Greater job satisfaction

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Constraints

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

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• Finally-
• If you have been
• Thanks for Listening