Chronic Disease Management

1. Chronic Disease Management Delivering a system in Primary Care October 2002

2. Why a systematic approach to CDM? • Lots of work in ordinary consultations • Involvement of team is necessary • All doing similar things • NSF standards to be met • Need to deliver care from an evidence base • Patients have expectation of standard of care • Equity of care • Other targets e.g. new contract, PCT targets etc

3. Which disease areas? • CHD • Hypertension • Diabetes • Asthma • Epilepsy • Thyroid disease • Others to come

4. What is needed to make it happen? • Some defined standard e.g. NSF for CHD • A systematic approach • Some clinical protocols

5. The systematic approach • Accurate registers of those with active disease manual or computer • Accurate identification of those at risk • Registers actively used and validated • A committed clinical team meeting regularly • Agreement re appropriate management

6. Systems needed for 2 groups • Those with existing disease • Those with a new/future diagnosis

7. About Disease Registers • To organise disease management effectively and efficiently • To measure clinical outcomes and performance of a target group • Provide epidemiological data of prevalence/incidence to inform needs assessment

8. Identification of Patient Group • Agree what constitutes the disease • e.g. CHD • Heart failure, non-rheumatic AF, angina as a clinical syndrome, MI • Positive EST/thallium scan • Arterial disease • Coronary artery surgery/revascularisation

9. Identifying data • Know how this data is recorded in your current system, e.g. manually, computer, Read code sets • Agree future recording system • Agree how new diagnoses will feed into system

10. Strategies for finding patientseg with CHD • Search for those with diagnosis e.g. IHD • Search other known high risk groups e.g. diabetics • Drug searches – nitrates, low dose aspirin, warfarin, nicorandil, digoxin, statins • Opportunistic case finding – clinician recall, other PHCT members, pharmacist, reception, prescriptions, posters, hospital discharge letters, correspondence • Validate existing registers – should find 3-5% practice population

11. Which model of care? • Special clinics? • Protected time? • Opportunistically, but with structure? • Targeted contact? • What about those with other chronic disease? Joint review e.g. CHD/Diabetes • Length of appointments, frequency of attendance

12. Call and Recall System • How will this be managed? • Who will manage this system? • Invitation • Non-responders • Housebound

13. Who will be involved? • Nurses • Doctors • Support staff • ? resourcing

14. New/future diagnosis • How will these patients be picked up? • How will they be added to register? • When/how often should they be seen?

15. Evidence based interventions • Protocols/guidelines e.g. for CHD • Blood pressure management • Lipid management • ACE inhibitors for LV dysfunction • Beta-blockers for those post-MI • Warfarin/aspirin for AF • Tight diabetic control • Life style interventions

16. Protocols • Evidence based • Comfortable to in house situation • Specific and clear • User friendly • Embraced by all • Support nurses at higher level of autonomy to initiate and change treatments • Inclusive of structure and process • Dynamic and ever changing!

17. Tools • Dedicated record card/computer template • Invitation letter • Identification system/register • Recall facility • Risk calculation system • Evidence based, practice agreed protocol for clinical management

18. Audit • Constant! • Around structure, process and outcomes • Shared • Basis for clinical meetings • Validates/adapts and changes clinical practice