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Chronic Disease Management
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NHS Brighton and Hove's plans to respond to the rising prevalence of chronic disease are summarised below. The Kaiser triangle classifies this population as follows:
Level 3: Patients with multiple complex needs, at high risk of serious new adverse events, unscheduled care or emergency admissions. Known as Very High Intensity Users or VHIU’s
Single Assessment Process: This allows patients with long term health and social care needs to be assessed thoroughly and accurately, without duplication by different agencies.
Level 2: Patients with one or more chronic diseases, or multiple risk factors, or poorly controlled single disease, or special needs.
Level 1: Patients with a well controlled single chronic disease, who self manage most of the time.
Level 0: The well public, the vast majority of the population, people not actually ill at any one time.
- Kaiser triangle (48kb Powerpoint slide)
Level 3
Community Matrons
Six community matrons: six community matrons providing case management for identified VHIU patients from 17 GP practices. Aim to reduce emergency admissions, facilitate timely discharge, coordinate care, educate patients in their own care and manage their diseases effectively.
Case management : an alternative to Community Matrons, this Local Enhanced Scheme ( LES) starts for a one year trial in Spring 06 with the GP’s in 4 practices selecting VHIU patients for case management by a Multi Disciplinary team. The aims are as for Community Matrons.
Care home support team: work is in hand to provide a case management approach to VHIU’s identified in care homes with nursing and in future for residential homes.
Level 2:
Disease specific services: Specialist Nurses: 2 Community Heart Failure nurses to be appointed summer 06, Rheumatology Nurse in place, 2 Neurology Nurses in place, 1 Dermatology Nurse. COPD multi disciplinary team launch due in June 2006, Echocardiogram Service being introduced at Hove Polyclinic, summer 2006.
Medicines under review scheme: Under this pharmacists will go out to patient homes to review medication, educate and advise on self- management of medication.
Administrative support pilot for management of long term conditions LES: For practices who want to use their QOF data gathering to organise patient call and recall and care plans more effectively and to ensure patients have the level of support they want . Linked to CDM Education Module below.
CDM education module: For GP’s and practice staff, attendance will be through take up of the Administrative Support Pilot LES above. An accredited 5 day course run by Sussex University, this will focus on managing CDM effectively in practices and identifying of patients who are worsening, to pro actively deal with health crises before they happen. The first course will run in June 2006.
Level 1:
Primary prevention of CVD LES: This LES will enable assessment of patients for Cardio Vascular Disease earlier on and offer advice and care to them to prevent and delay the disease developing. This builds on data now being captured for QOF and will help achievement of maximum points.
Extension of the Expert Patients Programme to take GP nominated Patients
Self Care Strategy: Under development, this will cover the means by which we can encourage, educate, inform and support patients to care for themselves.
Patient education: DESMOND– patient education initiative for Diabetes Type 2 in 2006/07
Level 0:
The Active Living Strategy: Includes smoking cessation, food and weight management posts, exercise and behavioural change courses.
Healthy Cities: Is about ensuring health considerations are factored into transport and urban planning decisions. In 2006/07 transport and urban planners are being trained to conduct Health Impact Assessments. HIA’s will be conducted on two major building projects.
Across Levels 1,2,3:
Tackling health inequalities: The findings of an audit of CHD in Brighton and Hove will be acted upon and a Diabetes equity audit will be conducted this year.
Care plans: work to identify the optimal care plan for each situation in 2006/07.
NSF implementation: ongoing task to comply with national best practice.
Exercise referral LES by taking up this LES in 2006/07, 10 practices will be able to trial GP referral of patients to a clinically approved exercise scheme.
Integrated Care Pathway Improvement Initiatives: disease specific process improvement work ongoing for Diabetes, COPD, Stroke, Asthma.
Falls service being implemented in 2006/07
For an update/any questions, please contact anne.younger@bhcpct.nhs.uk or on 01273 545424.
