1

National Survey of Multi-morbidity in clinical practice with COPD as an

examplar

Dr Shoba Poduval Clinical Support Fellow and First5 GP

Survey

• 7 point questionnaire uploaded to survey monkey

– What did you do? How did you do it? Why? What prompted you?

– Overall impact -how this benefits patients, staff and the organisation

– Lessons learnt, what went well? What didn’t work well? Advice for others

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Survey

• Open 29.11.12 - 8.2.13

• Thirty four responses

• Thirteen reviewed- themes

• Five case studies

• Other Practices of note- telehealth

Preliminary Results

Themes

• Motive

• Patient selection & invitation

• Organisation

• Staff

• Housebound patients

• Outcomes

• Evaluation

• Challenges

3

Motives

• QoF

• PBC/CCG funding

• Improving patient experience

Patient selection & invitation

• Disease registers

• Disease severity stratification

• Specific patient selection criteria

4

Staff

• Practice team: GP’s, Nurses, HCA’s, admin staff

• Community team: District Nurses, Community Nurses, Social Services, Pharmacists

• Secondary Care

Housebound

• Visits by GP’s & Community Matrons

• On-going support from Community Matron & Social Services

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Outcomes

• Patient and staff satisfaction

• More appointment time available

• Medication adherence

• Reduced A&E attendance

• Projected savings

Challenges

• Training

• Organisation- time

• Resources- templates

• Funding

6

Discussion

• What is your experience of managing multimorbidity?

• Challenges?

• Suggestions?