Targeted, Patient Centred Care Planning for Elderly with Risk

39
Targeted, Patient Centred Care Planning for Elderly with Risk Australasian Long-Term Health Conditions Conference …Shaping our future health system Hywel Lloyd

Transcript of Targeted, Patient Centred Care Planning for Elderly with Risk

Page 1: Targeted, Patient Centred Care Planning for Elderly with Risk

Targeted, Patient Centred Care Planning

for Elderly with Risk

Australasian Long-Term

Health Conditions Conference …Shaping our future health system

Hywel Lloyd

Page 2: Targeted, Patient Centred Care Planning for Elderly with Risk

Targeted, Patient Centred Care Planning For

Elderly with Risk

Hywel Lloyd, Deb Connor & Pieter Degeling

All Taieri Health Centre Staff In Collaboration with Older Peoples Health

'Year of Care'

Page 3: Targeted, Patient Centred Care Planning for Elderly with Risk

Target Population – Level 3 patients Most frail elderly at risk of hospital admission Aims Reduce Emergency Department Presentations Reduce Hospital Admissions Improve quality of Care Objectives Implement patient centred management plan focusing on risk as they perceived it to be

Otago OPJ 2 - Year Of Care Pilot

Page 4: Targeted, Patient Centred Care Planning for Elderly with Risk

The Wellness Trajectory

Health Gain

Health Gap

Welln

ess

Time

Line A

Line B

Page 5: Targeted, Patient Centred Care Planning for Elderly with Risk

The Practices

• Mosgiel Health Centre 5 Practices 10012 patients

• 6.5 FTE GPs

• 4 FTE Practice Nurses

• Practice Manager Nurse Manager Gordon Road Medical Centre - 1 Practice 2064 patients

• 1.5 FTE GPS

• 1 Practice Nurse

• 1 Receptionist/Manager

Outram Medical Centre 1 Practice 1682 patients

• 1.2 FTE GPS

• 1 Practice Nurse

• 1 Receptionist/Manager

• Middlemarch – Sattellite practice 0.2 GPs Rural Practice Nurses

Page 6: Targeted, Patient Centred Care Planning for Elderly with Risk

Background

• Care Plus Implementation

• Frustrated

• Lack of specific focus

• Team working was not performing as well as possible

• Implementation was variable across the practices

• PHO struggled to achieve consensus at the practice level

• Wide interpretation of the inclusion criteria

• Strategic Vision Lacking

• No Analysis of process nor outcome of CarePlus programme

• Nationally 50% and 40% increase in ED and Hospital Admission

Page 7: Targeted, Patient Centred Care Planning for Elderly with Risk

Informed,

Activated

Patient

Productive

Interactions

Prepared,

Proactive

Practice Team

Delivery

System

Design

Decision

Support

Clinical

Information

Systems

Self-

Management

Support

Health System

Resources

and Policies

Community

The Organization of a General Practice

Wagner’s Chronic Care Model

Improved Outcomes

Page 8: Targeted, Patient Centred Care Planning for Elderly with Risk

Informed,

Activated

Patient

Prepared,

Proactive

Practice Team

Wagner’s Chronic Care Model

Improved Outcomes

Individualized (YoC) Plan

based model of care

Productive

Interactions

Delivery

System

Design

Decision

Support

Clinical

Information

Systems

Self-

Management

Support

Health System

Resources

and Policies

Community

The Organization of a General Practice

Optimising the Patient Journey

Page 9: Targeted, Patient Centred Care Planning for Elderly with Risk

Re-design of

practice clinical

information

system

Workforce &

capital

Re-development

Individual

Self

Management

Mobilizing

local support

services

Re-design of

practice decision

support

systems

Routine review

and service

improvement

'Purposeful System for Delivering

'A Year of Care'

Delivery System

Re-Design

Indvidualised YOC

Care Planning

Page 10: Targeted, Patient Centred Care Planning for Elderly with Risk

Paradigm Shift

Systematised approach to service provision.

Pieter Degeling

Helen Close

Deirdre Degeling

September 2006

Proactive Planned coordinated and adaptive Capable of focusing on both the health risks of identified populations and patients as well as their changing wants and priorities as they see these to be. Structured to facilitate routine improvement or adjustment review

Page 11: Targeted, Patient Centred Care Planning for Elderly with Risk

Population Stratification

Level 1 : 1585 patients

Level 3 : 303 patients

Level 2 : 2524 patients

100%

0%

W e

l l n

e s

s

Population Wide Prevention Level 0 : 9346 patients

Support Management Clinical Management Self Management

Page 12: Targeted, Patient Centred Care Planning for Elderly with Risk

Population Stratification - Enables

• Basis for understanding the population

• Improves Business & Financial planning

• Facilitates Workforce Analysis & Restructuring

• Re-Engineering the current didactic General Practice Model

• Targeted Care Planning

Page 13: Targeted, Patient Centred Care Planning for Elderly with Risk

Sub-Stratification

• EARLi screening tool

• Applied as a telephone questionnaire

• Administered to Level 3 patients and Level 2 patients that are enrolled for Care Plus.

Lyon et al:

• Predicting the likelihood of emergency admission to hospital of older people:

• development and validation of the Emergency Admission Risk Likelihood Index (EARLi). FPAA 2007

Page 14: Targeted, Patient Centred Care Planning for Elderly with Risk

Year of Care - Overview

• Patient generated care plan is central & focus of all

encounters

• Primary Health Care Nurses

• Facilitate Wellness Planning sessions,

• Record the individual's narrative highlighting goals &

risks and broker access to support services required to

attain these goals.

• Facilitate PDSA cycles to review goal attainment, &

plan adjustment.

SYSTEMATISATION for Individualised Care

Page 15: Targeted, Patient Centred Care Planning for Elderly with Risk

Targeted Care Planning

Produce a written and electronic browsable care plan for the patient :

Baseline statement of wellness

Risks with plans to address these risks

Obstacles that need to be overcome to maintain wellness

Scenario setting and planning

What I need to do to stay well: daily weekly monthly

Warning signs and Triggers - Addressed with intervention plans

Future care setting requirements and plans

Classifications Medication Medical Warnings

End of Life wishes

Huge paradigm shift for everybody

Page 16: Targeted, Patient Centred Care Planning for Elderly with Risk

Joint assessment of

Individual’s targets, goals

& risks

Personalised health plan

that specifies cycles of

activities that will

contribute to goal attainment

and address identified risks

Enacted plan

Joint outcome

review

Clinical management

Support services

Self management

Do

Study

Plan

PDSA improvement - An integral part of individualised care planning cycles

Act

Page 17: Targeted, Patient Centred Care Planning for Elderly with Risk

Changes the practice of the practice through:

systematising the cycles of sequences of

events whose occurrence or non occurrence

will significantly affect quality outcome and

cost for an individual patient.

Year of Care Service Model.

Page 18: Targeted, Patient Centred Care Planning for Elderly with Risk

Bi-Weekly Weekly Monthly Bi-Monthly

Individualized improvement cycles

Time

D

S S D

A

D

P A P

P

S

A

P

D S

A

Encounters initially face to face , later encounters may take the form of telephone

follow ups

Gains in locus of control & Wellness

Page 19: Targeted, Patient Centred Care Planning for Elderly with Risk

Pilot Population

Mosgiel Health Centre 62 out of 89 invited patients were enrolled with YOC Gordon Road Medical Centre 17 out of 24 invited patients were enrolled with YOC

Quantatative and Qualitative Baseline established

• heiQ, PHQ-9, Patient Satisfaction & Experience • Emergency Presentations and Admission Data

Outcomes Measured against these baselines

Page 20: Targeted, Patient Centred Care Planning for Elderly with Risk

Outcomes

Page 21: Targeted, Patient Centred Care Planning for Elderly with Risk

Health-Directed Behaviour 1 – 4 2.66 2.87 16 of 49 = 30.77 % Positive and Active Engagement in Life 1 – 4 3.26 3.30 12 of 49 = 23.08 % Emotional Well-Being 1 – 4 1.81 1.66 15 of 49 = 30.77 % Self-Monitoring and Insight 1 – 4 3.30 3.44 16 of 49 = 23.08 % Constructive Attitudes and Approaches 1 – 4 3.63 3.63 8 of 49 = 16.33 % Skill and Technique Acquisition 1 – 4 3.12 3.20 23 of 49 = 46.15 % Social Integration and Support 1 – 4 3.45 3.46 23 of 49 = 46.15 % Health Service Navigation 1 – 4 3.63 3.68 9 of 49 = 18.37 %

Area Score Range Initial F up % Substantial Improvement

Aggregated heiQ results for Mosgiel Health Centre

Page 22: Targeted, Patient Centred Care Planning for Elderly with Risk
Page 23: Targeted, Patient Centred Care Planning for Elderly with Risk
Page 24: Targeted, Patient Centred Care Planning for Elderly with Risk

Outcome Data – ED Attendances

Admission

Risk % EARLI

Patient Group N Pre YoC

Dec 2008 - Nov 2009

Post YoC

Dec 2009 – Dec 2010

47% Year of Care 16 0.44 0.31

Control 45 0.6 0.42

55% Year of Care 10 0.6 0.5

Control 21 0.62 0.81

Page 25: Targeted, Patient Centred Care Planning for Elderly with Risk

Outcome Data – Admissions

Admission

Risk % EARLI

Patient Group N Pre YoC

Dec 2008 - Nov 2009

Post YoC

Dec 2009 – Dec 2010

47% Year of Care 16 0.94 0.81

Control 45 0.62 0.89

55% Year of Care 10 1.1 0.8

Control 21 1.05 1.29

Page 26: Targeted, Patient Centred Care Planning for Elderly with Risk

Outcome Data – Bed Nights

Admission

Risk % EARLI

Patient

Group

N Pre YoC

Dec 2008 - Nov 2009

Post YoC

Dec 2009 – Dec 2010

47% Year of Care 16 5.88 3.5

Control 45 2.82 4.13

55% Year of Care 10 5.1 4.1

Control 21 5.76 7.05

Page 27: Targeted, Patient Centred Care Planning for Elderly with Risk

Minimum prerequisites for implementing

Ability to stratify population to quite detailed level (PAT , EARLi) – accurate and consistent clinical coding required.

Analysable secondary care activity data sent to primary care

System that can support an electronic Care Plan

Staff with skills in person centred interactions with patients

Capacity (financially and personnel) to conduct Year of Care sessions

Enthusiastic staff within the team to drive the project forward to reason with the huffers and puffers and nurture the deep sighers!

Lessons Learned

Practice level impact - Emergence of a purposeful system

Page 28: Targeted, Patient Centred Care Planning for Elderly with Risk

Other Lessons

It requires authorisation, commitment & support from a practice’s senior clinical leader who puts in time and indicates ownership. It’s not about adding something into what is already there. (Not 'Plug and Play') Nor is it about cutting something out of the existing weave and inserting a patch, but recasting the weave with a crochet hook) It is a complex re-learning process which needs to be carefully staged and whose effects emerge over time. We need to realign financial incentives.

Page 29: Targeted, Patient Centred Care Planning for Elderly with Risk

Thank You...

Page 30: Targeted, Patient Centred Care Planning for Elderly with Risk

Healthy Populatio

n

End Stage Death

Precursor Risk

At Risk Early Disease

Symptomatic Disease

Practice Clinical Information Systems

Advanced Disease

Chronic Disease Continuum

Information Strategy

The ability to analyse the population to identify patients - At risk: at all stages of the disease continuum - Why are they at risk, What are their risks - Manage intervention programmes, scheduled care episodes - Recall Prompts & follow up including non attenders - Monitor Performance: Process & Outcomes Measures

- Apply appropriate care plans at different disease stages

Page 31: Targeted, Patient Centred Care Planning for Elderly with Risk

Level 1

Level 3

Population Stratification

Level 1

Patients with risk factors for developing a long term condition

Essential Hypertension

Pre- Diabetes

Smokers

BMI > 30

Level 1

Precursor Risk

At Risk Early Disease

Symptomatic Disease

Advanced Disease

Precursor Risk

At Risk Early Disease

Symptomatic Disease

Advanced Disease

Level 2

Level 2

Patients with one or two Long term Conditions

Level 3

Patients with three or more Long term Conditions

Page 32: Targeted, Patient Centred Care Planning for Elderly with Risk

Health & Social Services Individual standing, voice and volition

Service Appropriateness & fragmentation

Flexibility, Acceptability

Availability, Accessibility

Incentives, Cost

Health Behaviours Alcohol/Drugs

Diet and nutrition

Physical activity

Sexual health

Smoking

Clinical Profile Disease severity

Co-morbidity

Existing poly-pharmacy and medication regimens

Patterns of service usage

Activities of daily living

Personal Profile Role models and norms inherent in cultural orientation

Self-efficacy/self esteem

Health locus of control

Health literacy

Health beliefs/attitudes

Living Circumstances Housing

Safety in the home

Living alone

Living with a dependent

Availability and quality of personal support

connectedness/interdependence with other

Socio-Economic Profile

Age, Gender , Employment status, Income

Cultural background

Environmental Factors

Personal safety

Transport

Exposure to pollution and other hazards

Adapted from Hawe P., Degeling D., & Hall J. (1990) Evaluating Health Promotion, Elsevier, Australia

Risk Assessment Criteria

Page 33: Targeted, Patient Centred Care Planning for Elderly with Risk

Practice Level Impact

GP envolvement has moved.

At pilot initiation we had look warm support from 2/5 GP partners

Now all partners consider Year of Care to be part of core business and support

Year of Care plan at the core of GP - patient encounters

Centrality of nursing role within long term conditions acknowledged

Greater use of IT facilitating decision support systems.

Increase awareness of linking with community services.

Support for systems change re: scheduling, allocations of time, workforce allocation.

Workforce re-development

Page 34: Targeted, Patient Centred Care Planning for Elderly with Risk

What is going well

• Care Plus is more targeted.

• Electronic Care Plan & Patient Held Record

• Individualised PDSA based care planning and service improvement.

• Practice wide PDSA based service improvement

• Couple 'co-dependency' Care Planning

• Skill uptake by patient on crucial aspects of their self management.

Marked shift in locus of control

• GP & Practice Nurse Buy In

• Work Redesign & Staff Training

• Development of financial Modelling Tool – linkage with CarePlus.

Year of Care – Lessons Learned

Page 35: Targeted, Patient Centred Care Planning for Elderly with Risk

What needs further work:

System redesign to cope with distinct patient flows.

40% of encounters 10 minute GP consultations, 60% Year of Care model based management - Implications for scheduling, workforce assignment & space usage.

Improved data flow from secondary to primary care to trigger anlysis of variance (such as A&E attendance and/or admission) so that causes can be identified and individual care plans can be adjusted with the patient

Harmonise secondary care with YOC care planning

Linkage with NASC processes

Better inventory of wrap around services

Re-alignment of incentives for primary care.

Year of Care – Lessons Learned

Page 36: Targeted, Patient Centred Care Planning for Elderly with Risk

Based on pilot findings DHB and PHO – commited to the rollout of YOC Model

across our region. Strategy will recognise that substantive redesign can only occur

on a practice by practice basis Consolidate work in Taieri Practices Select 4 more practices for detailed rollout and refinement of tools viz Stratification, electronic care plan variance recording & analysis, service harmenisation between primary and secondary care and related information flows. Resources allocated for staff and technical support to undertake the developmental work. Three year strategy Year 1 - PHO wide initiatives & rollout to 4 practices Year 2 - Consolidation within practices Year 3 - Initiate PHO wide payment system rollout

Where To From Here?

Page 37: Targeted, Patient Centred Care Planning for Elderly with Risk

Year of Care Service Model.

Changes the practice of the practice through:

systematising the cycles of sequences of

events whose occurrence or non occurrence

will significantly affect quality outcome and

cost for an individual patient.

Page 38: Targeted, Patient Centred Care Planning for Elderly with Risk
Page 39: Targeted, Patient Centred Care Planning for Elderly with Risk

Re-design of

practice clinical

information

system

Workforce &

capital

Re-development

Individual

Self

Management

Mobilizing

local support

services

Re-design of

practice decision

support

systems

Routine review

and service

improvement

Practice level impact

Emergence of a purposeful system

Delivery System

Re-Design

Indvidualised YOC

Care Planning