Dr John D Dean, MD FRCP

1. Designing and Delivering care for people with Long Term ConditionsWhat can the NHS learn from other countries?What can the NHS teach other countries? Dr John D Dean, MD FRCP Medical Director for Quality and Care Improvement,Consultant Diabetologist, Bolton Primary Care Trust. Health Foundation Fellow, Institute for Healthcare Improvement

2. Objectives Share my experience • Early learning • Developing integrated diabetes service • A broader perspective • Year’s sabbatical at IHI\USA studying improving chronic care • Bringing the lessons home • Translating learning into designing and delivering care for a local population in NW England • Learning for others from NHS

3. Diabetes Care in Bolton • 12,300 people registered with diabetes = 4.6 (1.9-6.3) % • 9.3% south asian population - Gugerati • 57 General Practices, • 90% of practices structured diabetes care • 80% patients primary care only • Community based diabetes specialist team • Bolton Diabetes Centre - 1995 • 20% of patients, mainly complex or at transition

4. Ethos of Specialist Team To facilitate and provide high quality patient centred diabetes care throughout Bolton, through education and expert practice

5. Bolton Diabetes CareKey time points 1989 Regional Review of Diabetes Care 1992 Multi-agency planning group established (LDSAG) Plans for “town centre” Diabetes Centre for specialist care Primary Care Education days commenced 1994 Consultant Physician and lead Nurse appointed Care agreements established with each general practice 1995 Bolton Diabetes Centre opened – Town Centre 1995 -2002 Specialist Clinics developed 2nd Physician appointed Extension of primary care professional education Expansion of nursing team through “opportunities”, ‘ Nurse Consultant 2001 External Diabetes Services review 2002/3 NSF Diabetes 2004 Specialist Service transfers to of PCT 2006 Our Health, Our Care, Our say ‘Bolton’s Diabetes Journey’

6. External Review - 2000/1 STRENGTHS • Strong leadership from Diabetes Centre • The Diabetes Centre team is able to offer multidisciplinary consultations for patients with complex needs • Many examples of good and innovative practice in specialist, primary and community care • Practice nurses-extensive training and experience in diabetes (10 yrs) • Podiatry screening service consistently praised • Good teamwork in the management of diabetic foot ulcers RECOMMENDATIONS • Reduce variation in primary care • More practice based education is needed • More specialist interaction with primary care

8. Diabetes Care in BoltonTHE VISION:“INTEGRATED DIABETES CARE” Patient centred not organisation centred Care should be delivered • at the appropriate time, • in the appropriate place, • by the appropriately trained professional, • for that patients present needs

9. Objectives of Integrated Diabetes Care in Bolton • fully integrated service • avoid any gaps or duplication in service • smooth and quick referral from primary care for advice and management plan • increased specialist input into primary care settings • consistent high quality patient centred care

10. Define level of provision by Practice

11. Complemented by the Diabetes Specialist Service

12. 2003

13. Strategy

14. 2007

15. Pre requisites for integrating care • Shared vision • Clear accountable leadership • Defined and agreed roles and responsibilities of staff and organisations • Common Patient Record and Information Integrated Management - the local managed diabetes network Specialist team part of PCT by April 2004

16. PRIMARY CARE STAFF Clear remit and managerial support to deliver level of care More access, support and education from specialists, to agreed level In practice time for education More care delivered in primary care SPECIALIST STAFF Clear remit and managerial support Time spent in primary care Devolving appropriate care to primary care More time on education and support and advice for primary care More time for intensified care for appropriate patients, Complex needs, Transition. What does this mean for Staff? ALL - Involvement planning integrated care Closer Working relationship

17. What does this mean for Patients? • Complete care by adequately trained professionals • Local care • Consistent care • Access to specialist advice • Seen in most appropriate care setting • Involvement in planning and monitoring integrated care

18. Early lessons in developing and delivering integrated care for a population – diabetes • It takes time • Shared vision, leadership and purpose • Education, education, education • Devolved management and decision making • Multi-agency planning – patient involvement • Use external influencers • Appropriate specialist care depends on a skilled primary care workforce • Recognise variation

19. The journey – Bolton to Boston and back Why? What?

20. Bolton to Boston - Objectives • To learn theory and practice of quality improvement techniques in healthcare • To become an “expert” in the delivery of chronic disease care by • Studying and exploring current theory • Observing systems and current practice in US and elsewhere • Particular emphasis on integration, and learning from one disease area for others • Develop capacity and skills leadership and facilitation

21. Boston and beyond • IHI and (HSPH) • Formal and informal learning of QI • Interacting with many healthcare systems, leaders and clinical teams • Worked with clinical teams in collaborative learning (Office Practice, Quality Allies, BPHC) • Visited healthcare systems and opinion leaders to explore the delivery of chronic disease care • Shared learning and growth through fellowship

22. IHI examples • 100,000 lives campaign – 80 % of American hospitals working to reduce mortality • BPHC – 900 community based clinics for “underserved”, collaboratives in diabetes, depression, finance, clinic transformation • Kaiser Permanente – A Kaiser model for spreading best practice • Improving primary care by innovative use of IT • RWJF - Transforming care at the bedside, • IMPACT - Emergency redesign, Flow, Reliability, • GLOBAL – HIV aids SA, Botswana, Tanzania • Maternal Mortality , malawi

23. McColl institute, Group Health, Virginia Mason, Everett Clinic Maine Health, Dartmouth Hitchcock Health Partners, Park Nicollett, Mayo Clinics Cambridge Health Alliance, MGH, Joslin Clinic, Beth Israel Deaconess, VA Massachusetts, Renaissance Health Kaiser Permanente (CMI), Life Masters, Stanford University Patient Education Veterans Administration Connecticut Kaiser Permanente, Southern CA Geisinger Health Alaska Native Health Care Clinical Teams throughout the country in Collaboratives

25. Personal Learning • As healthcare professionals we try and manage disease rather than trying to enable people with long term conditions to live their lives as fully as possible. • There are well described models and approaches to improving care, that it can’t be achieved by education and planning alone • That many health service structures inhibit the development, delivery and improvement of appropriate care • That these obstructions are common to most health systems but potentially least within the NHS than any other health system in the world

26. Specific Learning • Chronic Care • Very widespread use of “The Chronic Care Model” but only components. • Generally UK “ahead” of US • - registries, primary care, specialist involvement, multidisciplinary working • US more use of “Power of patient peers” • Multiple approaches to Care/Case management/Care coordination • Boundaries of current care in UK and US are integration of care Quality Improvement • Many methods and approaches, widely used and systemic in US • Need to develop a learning organisation with quality as a key strategy and goal, from leadership to micro-system • Start with measurement and feedback, and small simple changes

27. How to improve care of people with long term conditions

28. Healthcare Organisation leadership Self management education Decision support Community resources Planned care Population registries Self Management support Composition of care team Patient Centred consultation Community awareness Behaviour Change/ Motivational interviewing Shared Decision making Care coordination Skills requirements for patients and practitioners Patient activation Advocacy Case management Use of IT

29. Putting it all together

30. Current methods • The Chronic Care Model http://www.improvingchronicillnesscare.org • Planned Care http://www.ihi.org/IHI/Results/WhitePapers/InnovationsinPlanned+CareWhitePaper.htm • The medical home (children) Paediatrics 2004 113(5) 1545-1547

31. “Planned Care” • Planned care is the term used in the US for care that results from the chronic care model • The key elements for clinical teams are: • Disease Registers Aiming at optimal care for all • Planned Care Visit (individual or group) • Self Management Support Incorporating self management education, goal setting and action planning

32. Remaining challenge is integrating care • Integrating care across professional/organisational divides between specialists and generalists • Integrating care across conditions and needs for people with multiple conditions

33. Three Tiered Approach to Care for Long Term Conditions Clinical Method Clinical Interaction Designed Personal Care Care Team Chronic Care Model Health Care Organization

34. Health care organisations Use the framework of Chronic Care Model to support clinical teams and clinical interactions • Health Care Organisation • Clinical Information Systems • Delivery System Design • Self Management Support • Decision Support • Community

35. The two key cycles in designed care for people with long term conditions • The population care cycle • Planned use of registers • The designed personal care cycle • Designing effective patient specific care

36. Population planning cycle

37. Principles of population planning cycles • Care for the population is a fundamental component of chronic care • Active management of population registers is required • A measurement strategy is needed to monitor care outcomes • Population register management must be linked to clinical care • Roles of clinical team members in population management need defining, and their time to fulfill this role planned and protected • Plan regular team review of registry data • Regular team based review of population care should lead to continuous improvement of care delivery and outcomes

38. Designed Personal Care Cycle for continuing care • Collaborative care plan • Goals • Personal action plans • Self Management education • Treatment • Support/care team • Review and follow up • Continuing review and support as per care plan • Where • When • How • By whom • Planned • Assessments • What • Where • How • When • How often

39. The concept of care cycles for designed personal care • Care for chronic conditions is a continuous process that has a number of repeated elements • Certain elements of care should be delivered at a predetermined frequency • Assessment is essential to inform care planning • Typical care cycles can be designed for specific diseases or parts of the population, but are then modified or combined for a personal care cycle • Separating components of care into elements of care cycles helps clinical teams and patients to plan • reliable care, • the role of members of the care team, • the location or mode of each component of care

40. Members of the Care Team for people with long term conditions • Patient • Patient’s family and significant others • Primary Care Physician • Other clinical members of the primary care team • Non clinical members of the primary care team • Specialist clinicians • Peer advisors/mentors Essential roles to be assigned in the care team are: CARE COORDINATOR, ADVOCATE, KEY CONTACT

41. Designed Personal Care Cycle for Diabetes Clinic A • Collaborative care plan • Goals and action plans • Self management education • Treatment • Support/care team • Review Continuing education, treatment and review as per care plan “Annual Assessment” Risk factor assessment for complications, HbA1c, Lipids, Blood Pressure, Smoking Status, Body Weight/ (BMI/Waist circumference) Assessment of treatments, Medicines Management, Hypoglycaemia assessment and advice, Insulin use and injection site assessment Knowledge and Self Care Assessment including glucose monitoring and nutritional assessment Psychological well being assessment Dental Assessment Sexual Health Assessment Screening for presence of complications. Retinopathy, Foot problems, Proteinuria and Microalbuminuria, Cardiovascular Disease, Serum Creatinine Treatment of Diabetes Complications

42. Designed Personal Care Cycle for COPD • Collaborative care plan • Goals and action plans • Self management education • Treatment • Support/care team • Review Continuing education, treatment and review as per care plan Functional Assessment e.g. walking distance Risk factor assessment, Smoking Status, Body Weight (BMI/Waist circumference) Cardiovascular Assessment Blood Pressure, Lipids Assessment of treatments, Medicines Management, Knowledge and Self Care Assessment including use of devices, self care plan. Emergency care plan Psychological well being assessment Physiological Assessment Vitalograph, O2 Saturation

43. Designed Personal Care Cycle for 65 Man with Diabetes and COPD • Collaborative care plan • Goals and action plans • Self management education • Treatment • Support/care team • Review Continuing education, treatment and review as per care plan “Annual Assessment” Risk factor assessment for complications, HbA1c, Lipids, Blood Pressure, Smoking Status, Body Weight/(BMI/Waist circumference) Assessment of treatments, Medicines Management, Hypoglycaemia assessment and advice, Insulin use and injection site assessment Knowledge and Self Care Assessment including glucose monitoring and nutritional assessment, Emergency care plan Psychological well being assessment Sexual Health Assessment Vaccination: Flu, Pneumovax, Dental Assessment Presence of diabetes complications – Screening. Retinopathy, Foot problems, Proteinuria and Microalbuminuria, Cardiovascular Disease, Serum Creatinine Screening Studies Colonoscopy, PSA, Urinalysis Physiological /Functional Assessment Vitalograph, O2 Sats, walking distance Treatment of Diabetes Complications

44. Personalising Care cycles Segmentation • Classically we segment the population and care needs by diagnosis, “control” of the disease, age or racial background • Different intensities and types of care are required for different parts of the population • When designing typical care cycles, teams should consider how they will segment the population, and how the cycles will vary. This is the first step in personalising care cycles and can be matched to the available resources • Using other measures, such as confidence to self care, or a measure of patient activation as well as biomedical “disease control” to define care needs should be considered.

45. Three Tiered Approach to Care for Long Term Conditions Clinical Method Clinical Interaction Designed Personal Care Care Team Chronic Care Model Health Care Organization

46. The Old Single acute curable disease One to one doctor/patient interaction Face to face individual care Dominant physician role The New Multiple chronic disease Healthcare teams, group visits, joint appointments, peer led education Telephone, email, web based, population care and self care Partnership between care givers and activated patient and family Clinical Care Needs

47. Clinical Interface Use “Clinical Method for Chronic Disease” for patient centered care • Describes the skills and tools that clinicians and patients need for effective assessment and collaborative care planning • Describes specific methods for certain care needs e.g. joint consultation, clinical team functions, telephone care, email care, self assessment, group care

48. Collaborative Care Relationship building Understanding the whole person Agenda setting Assessment and problem solving (includes barriers to self care, and self assessment) Education (teach back) Shared decision making Goal setting and action planning (includes barriers) Agreeing the care team, follow up and support Care team functions Advocacy Access Care coordination Coaching Clinical Interface Use “Clinical Method for Chronic Disease” for patient centered care

50. Health System Performance in Selected Nations 2004 Commonwealth Fund International Health Policy Survey of Adults' Experiences with Primary Care. (8,500 adults) 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (7000 adults) 2006 International Health Policy Survey of Primary Care Doctors (5000 docs) OECD Health Data from 2004 and 2005 Compiled by Katherine K. Shea, Alyssa L. Holmgren, Robin Osborn, and Cathy Schoen. May 2007