The Pharmaceutical Journal
Vol 272 No 7299 p618-619
15 May 2004

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Care model could change approach to chronic disease management in NHS

In this article, Ian Winstanley describes an innovative model of care for the elderly frail that originated in the US and has now been adopted in a primary care trust in Luton

In November 2003, members of staff from nine primary care trusts set out for Minneapolis in the US, invited by the Department of Health to experience the Evercare model of care for the elderly frail. Along with colleagues from my own PCT, Luton, and our local secondary care provider, the Luton and Dunstable Hospital, I set off for what would be one of the most instructive and useful visits of my career.

In a visit earlier in the year, senior figures close to the Prime Minister’s office and the Department of Health had been shown a model of care that could fundamentally change the approach to chronic disease management in the NHS.

Costs for the elderly frail and in particular the elderly with chronic diseases in the US had been spiralling for the health insurance sector and something had to be done. Evercare, a new subsidiary of the US giant, United Healthcare Group, had determined that although secondary care costs could be controlled by a fixed fee (similar to our health resource groups) what really cost the patient and the company was the rehabilitation required following secondary care intervention. If the hospital intervention went well the patient would be returned home and rehabilitation would be short and effective in re-establishing independence. But in too many cases the patient would stay too long and either get an acquired hospital infection or would “go off their legs” (not unlike our own experience). The cost to rehabilitate either or both of these conditions was astronomical and as the data were crunched it became the focus for change by the Evercare team. It was not difficult to see that for the elderly with chronic disease two things were important:

· If you could avoid the admission altogether, costs for the inpatient stay were eliminated and the rehabilitation costs potentially would be reduced
· Patients without secondary infections or disorientation were rehabilitated far more effectively

Therefore, by focusing on the patient pathway this group of patients would remain as independent as possible with as little nursing or medical intervention as possible.

In this way the programme aims were established. They are:

· To reduce illness and manage chronic conditions for high risk or chronically ill older people
· To help keep older people healthier longer, and minimise avoidable or over-long hospital stays
· To promote maximum independence and function
· To provide a systematic approach to chronic disease management

To achieve this the focus of the work had to shift back from clinicians, and the system, to the older people and the network of carers and family who interact with them during their everyday lives.

So, not too difficult or particularly challenging yet — you might say “We do that here now do we not?”. Well, we do undoubtedly agree that the principles are sound but how many places in the country, when they really look at their system, can say that they honestly practise the Evercare core principles?

The programme draws on a set of core principles. These are:

· Treatment for older people must focus on the whole person with all the “interventions” meeting the goal of preserving independence, function, comfort and quality of life
· Primary care is the central organising force of health care for older people
· Medical care for older people is delivered in the least invasive manner in the least intensive setting possible
· The side effects of polypharmacy should be recognised and minimised, medicines management should be improved
· Data drive decisions — good quality information is used to evaluate progress and changes needed, both for the older people themselves and the project across the community

The Evercare model of care uses proactive planning with patients and relatives to achieve agreement on the appropriate care wanted by patients and their families. The care planning and delivery relies heavily on the use of specially trained nurses called advanced primary nurses (APN). They carry out an in-depth baseline assessment of need, assess and diagnose conditions, implement care and instigate early intervention if the patient’s condition deteriorates. Once identified as benefiting from this model the older person will have the opportunity to remain on the caseload of the appointed nurse for the duration of his or her life.

The core principle of this model is educating patients and their carers to recognise and understand their condition and know when to seek intervention from an APN to avert a worsening condition. As much care as possible is provided at home, and avoidable admissions to hospital and long-term care are reduced. This model works equally well both in the person’s home as well as in registered care homes.

To ensure this happens we have had to work hard to embed three themes into all the clinicians involved.

Communication
· Awareness by the primary care team of the role of the APN
· Timely exchange of clinical information between GPs and APNs, sharing a joint communication system
· Access to the GP by the APN when guidance is required either by telephone or in person

Partnership
· Development of semi-autonomous practice of the APN, based on clinical skill and trust
· Respect for each team member’s unique skills
· Recognition of skills shared by each team member
· Active involvement of all team members
· Clear vision of responsibilities

Growth
· Ongoing teaching and learning within the team
· Emphasis on increasing the APN’s role as appropriate

Transposing the model to Luton

All of this may seem either straightforward or pretty frightening, depending on your point of view. But the evidence, and the Americans have enough to require a separate company to handle it, and the real-life experience of both patients and clinicians prove that the model really works.

To transpose the model to Luton was less difficult than we imagined. With support from the Workforce Development Confederation we appointed four APNs (the Luton scheme now has eight). The contract with the Evercare team supplied us with the medical training from physicians and nurse practitioners that our nurses required and a set of competencies was drawn up. These have been subsequently incorporated into a master’s degree course, which all our APNs are required to complete.

The group of patients were identified by some key criteria, specifically:

· Two or more emergency admissions to accident and emergency in the previous year
· Patients with polypharmacy
· Patients with co-morbidity
· Patients identified by the health and social care community as the multi-faceted frail

The GPs have acted as mentors to the APNs during their day-to-day practice and through their extended supplementary prescribing course. The elderly care consultants have been available to undertake critical analysis whenever an emergency admission occurs to the elderly wards. Early on in the project it became apparent that this should not only be a way of developing nurses but that the team of allied health professionals we were relying on for expertise could, and should, be afforded the same opportunity and to that end we employed a pharmacist who will undergo exactly the same training as her colleagues. We hope that she becomes our first advanced primary practitioner.

Benefits of collaborative practice

The benefits of the system working collaboratively to address the needs of these patients have been dramatic. GP time is optimised, the need for a GP/APN partnership arises from the complex issues often associated with chronically ill, functionally impaired older people. The APN will:

· Provide proactive monitoring of chronic disease
· Perform complete organised assessment of the ill patient
· Ensure effective medicines management
· Co-ordinate and facilitate care across all settings with all health care providers
· Update the patient’s medical record
· Communicate with families and carers

In addition, care is enhanced for patients, families and other carers. Satisfaction with the efforts of the GP practice to provide and co-ordinate care is increased and advice and information is provided proactively. The APN closely monitors and reviews the total plan of care and teaches and helps the patient manage their own care, as well as acting as an advocate for the patient. In addition, care is provided in the most appropriate setting and the patient has access to the health system through one person.

Education

Perennially the NHS has innovated without the support of education and therefore the change cannot be either substantiated or developed. Once the initial innovators move on there are no building blocks to underpin the new practice.

In this model we have tried to ensure that education has been developed with the innovation.

The aim of education is to support nurses and allied health professionals practising at an advanced level in their transition to autonomous collaborative practitioners. The skill set develops the existing practice within all the professionals breaking the “glass ceiling” of medical only practice, specifically:

· Clinical assessment skills — history taking, physical examination
· Supplementary prescribing
· Diagnostic reasoning

These skills become an integral part of a master’s degree course.

The physical assessment and history taking skills reflect mental health needs, chronic disease aetiology, chest auscultation, gait and balance assessment. These skills need to be taught with the proactive/preventive model in mind. Assessment should to be undertaken against specialist “older people” competencies.

Pharmacological knowledge needs to be enhanced sufficiently to enable the advanced primary practitioners (APP) to carry out a medication review in conjunction with other professionals (if not a pharmacist APP).

Refined communication skills are particularly important within the collaborative relationship with GPs, acute trusts, community services, patients and carers, for example, sharing sensitive information with professionals, patients and families and providing the appropriate level of education to patients and their carers to empower them and enable them to make informed choices.

Data are required for analytical purposes for audit and commissioning, to identify the high risk group population and to share appropriate information once these patients are being seen by an APN. Data need to be used strategically to provide evidence of positive change.

Each individual area will have its own identified needs according to where they are with their information management and technology strategy and integrating records. When considering data collection and retrieval always consider how, why, when and by whom before deciding what is required.

Wider benefits

The model has been functioning for almost 12 months in Luton and the benefits have been dramatic. In addition to the benefits to the older people involved, there are likely to be other gains to the local population, its services and those who are involved in health and social care.

Reduction in admissions to hospital Avoidable admissions for the group of patients served in the US suggest a 50 per cent reduction for this population. The early experience in Luton suggests that figure is not wildly exaggerated.

High patient satisfaction The evaluation of the Evercare model in the US suggested a 97 per cent patient satisfaction with the service. This may be due to the close relationship that builds between the practitioner, the older people and their families, and the increased information and discussion that takes place about the likely progression of illness and the choices that patients have. Early indications in Luton suggest similar, if not higher, figures.

Efficiency The US experience is that this project saved 7 per cent on the federal government’s annual Medicare budget for this population. Early intervention, keeping older people well and reducing inappropriate admissions lead to more effective use of limited resources. Currently there is no equivalent information available in the UK but recent evidence suggests that 78 per cent of the NHS budget is spent on chronic disease management. If reproduced uniformly across the UK early indications seem positive for a significant reduction of spending in this area in the NHS.

Professional development The project offers opportunities to develop professional roles, specifically in nursing and allied health professionals. These new roles will challenge the boundaries of interprofessional working in a supportive and structured way. Accredited training to a recognised standard has been developed with local higher education providers. The aim is to develop clinical leaders of the future who will be able to influence the care pathway of the complex older person initially and then all those who are suffering with chronic disease.

The future

In Luton we have worked hard to anglicise a model that, although not beyond our understanding, had been beyond our want to do. But perhaps more than that, what we have tried to do is learn from the mistakes of previous innovation. We have “done the thinking”, supported the new roles with educational credibility and finally we are putting our money where our mouths and beliefs are and mainstreaming across our nursing and allied health professional workforce.

I now believe that we are a deal closer to fulfilling our promises to patients about being a health service as well as an illness service.

Further reading

· NHS National Service Framework for Older People. Available at www.dh.gov.uk
· Liberating the talents. Available at www.dh.gov.uk
· Implementing the NHS plan — 10 key roles for nurses. Available at www.dh.gov.uk
· NHS Plan. Available at www.dh.gov.uk
· Evercare. Implementing the Evercare programme — interim report 2004. Available at www.natpact.nhs.uk