Commissioning Care Pathways for Chronic Diseases

Commissioning Care Pathways

for Chronic Diseases

James GuptaMedical Student | University of Leeds

QIPP Lead | Windermere Medical Centre

[email protected]

Overview & Aims

What are pathways, when do we use them and why do we need them?

Developing a pathway-based approach to COPD commissioning

How can we measure the impact of pathways on patient care?

Commissioning for ‘whole person’ care

Our experience(overview of the StHealth COPD project)

© James Gupta 2012 | [email protected]

What is a ‘Pathway’?



Post-op complications fell 33%Inpatient deaths by 40%


“Integrated Care Pathways (ICPs) provide a template for multi-disciplinary care that is evidence-based and co-ordinated.” – Clinical Governance, NHS Scotland 1

“An integrated care pathway (ICP) is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.” – Oxford University Medicine 2

“A care pathway is anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency 3

1) NHS Scotland Clinical Governance, What are integrated care pathways, http://www.clinicalgovernance.scot.nhs.uk/section2/pathways.asp2) Bandolier, Integrated care pathway, http://www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html

3) Welsh Assembly Government, Innovations in care 2003.


http://www.clinicalgovernance.scot.nhs.uk/section2/pathways.asp

http://www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html


“A template for multidisciplinary care that is evidence-based and coordinated.” – Clinical Governance, NHS Scotland

“A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.”

– Oxford University Medicine“Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency

Multidisciplinary



“A template for multi-disciplinary care that is evidence-based and coordinated.” – Clinical Governance, NHS Scotland

“A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.” – Oxford University Medicine“Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience.”- Welsh National Leadership and Innovation Agency

Multidisciplinary Evidence-based






Multidisciplinary Evidence-based Anticipated






Multidisciplinary Evidence-based Anticipated

Local & Specific


Available from sthealth.org.uk/copd_resources.htm

Why do we need pathways?

Time & budget restraints

Patients receiving care from different professionals

Need to make care as efficient as possible and reduce variation

Every patient is unique, but key features will be seen repeatedly


When do we use pathways?

We all use pathways, every day

Structured decision-making process based on knowledge (evidence) and experience


What are the benefits of using pathways?

Patients receive care that is not only more consistent, but also of a higher standard and more up to date with the latest evidence

Clinicians feel more confident and can get more done in less time

Resources are used more appropriately

Emergency / non-elective admissions can be reduced

Rotter et al Cochrane Review 2010

1) Rotter et al, Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006632. DOI: 10.1002/14651858.CD006632.pub2.

2) Campbell H, Hotchkiss R, Bradshaw N, Porteous M, Integrated care pathways. BMJ 1998, 316(7125):133-7.3) Lowe C, Care pathways: have they a place in ‘the new National Health Service’? J Nurs Manag 1998, 6(5):303-6.


Developing a Pathway Approach to COPD Commissioning Multidisciplinary

Chest physicians GPs Practice nurses COPD / community nurses Practice managers Pharmacists Respiratory physiotherapists Smoking cessation advisers Spirometry technicians

Committed

Lead: clinical and managerial experience


Developing a Pathway Approach to COPD Commissioning Assess your current patient

journey: Time wasters Black holes Bottlenecks

Plan a new patient journey THINK OUTSIDE THE BOX!

Listen to the views of ALL your MDT equally regardless of ‘seniority’ or qualifications. Expect some ‘culture shock’ between primary and secondary care professionals, encourage it!


Primary/Secondary Care Conflict

Peter – Consultant chest physician Wendy – Practice nurse


Primary/Secondary Care Conflict

Peter –chest physician Wendy – Practice nurse

“Patients should have full post-bronchodilator spirometry performed by an accredited technician every time they come for a review – other measures of lung function simply aren’t accurate enough”

Liz – Pathway lead

“We’re really busy in primary care so don’t

always have time to do spirometry – often

we can see how a patient is getting on

by asking them questions, their

general appearance, peak flow etc”


Developing a Pathway Approach to COPD Commissioning

The hardest part

Simply distributing the final pathway will not work

Has to be done alongside structured clinician education

Advertise the mutual benefit: Improve patient care AND Make your job easier!

Resistance to change


Measuring the impact of pathways on patient care

QOF Flu jab L12M FEV1 L15M MRC score L15M

Not acceptable!!

Many ways to measure REAL changes in the patient experience

Identify them early!


Commissioning Quality Markers: Measuring the impact of pathways on patient care

Must ultimately focus on REAL clinical outcomes

May take many years to see full benefit of these

Surrogate endpoints in meantime

Cost reductions / QIPP

Primary Endpoints

Surrogate Endpoints

Process Markers


Commissioning Quality Markers

Should focus on real outcomes where possible Admissions /

Exacerbations Quality of life

(King George, PHQ9) Smoking quit rates

Costs Referrals Prescribing

% referred for pulmonary rehab


Commissioning for Whole-Person Care COPD is being increasingly seen as a systemic disease with

associated co-morbidities: Depression Heart Failure Osteoporosis (corticosteroid-induced) Hypertension Cardiovascular disease Lung cancer Bronchiectasis

Yet current care-pathways do not operate like this – definitely something to bear in mind

Good model: diabetes – common co-morbidities / complications are treated and screened for under one (relatively) cohesive model

1) Barnes PJ, Celli Br, Systemic manifestations and comorbidities of COPD. Eur Respir J 2009, 33(5);1165-85


Case Study: StHealth COPD Project

Joint working initiative with GlaxoSmithKline(DH toolkit)

StHealth Practice Based Commissioning Consortium (now Shadow CCG)

Focused on enhanced management AND early detection of COPD

Pathway-based

Led to reduction in hospital admissions and

prescribing costs, increase in patient satisfaction, quality of

reviews,


Key Pillars


QIPP


Summary Pathways are multidisciplinary, evidence-based, local &

specific

Take best available evidence and adapt it to local needs & provision

Can increase standard of care for chronic conditions

Reduce costs, admissions/bed days and improve quality of life

Need to identify commissioning quality markers


Commissioning Care Pathways for Chronic Diseases

Health & Medicine

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