The Pharmaceutical Journal
Vol 272 No 7299 p601-602
15 May 2004

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Better chronic disease management

Next week, senior managers of organisations across the NHS will gather in London to discuss chronic disease management. It is an issue that is high on the Government’s agenda, and pilots of two US systems of managed care are under way in England. Clare Bellingham (on the staff of The Journal) reports

Related websites
Evercare (www.evercareonline.com)
Kaiser Permanente (www.kaiserpermanente.org)

Chronic diseases need to be better managed. Not only does good chronic disease management make a difference to patients’ quality of life but it also makes sense for the health service. Put simply, good management of chronic diseases cuts costs. If patients’ diseases were better managed, they would be less likely to have acute episodes that require intensive management, perhaps in hospital. They would also be likely to live a longer, healthier life. So improving chronic disease management is something that has implications for all pharmacists no matter what care setting they practise in. Having said that, one of the aims of good chronic disease management is to keep patients out of hospital so much of the work will be undertaken in primary care.

Chronic diseases represent a considerable burden to the NHS. With approximately 17 million people in Great Britain and three-quarters of people aged over 75 years having a chronic disease, incidence of chronic disease is high and growing. Research suggests that 80 per cent of GP consultations relate to chronic disease and two-thirds of emergency hospital admissions are for exacerbations of chronic diseases. Patients with multiple chronic diseases represent a particular challenge and costs for these patients are six times higher than those for a patient with only one chronic disease.

“Chronic disease management is a major policy development in health now. It will have a fundamental impact on health care delivery in the next five to 10 years,” says Clive Jackson, chief executive of the National Prescribing Centre. “As chronic disease management tends to involve medicines, any change in the management of chronic disease will have an impact on managing medicines and therefore impact on pharmacists.”

Two systems of chronic disease management used in the US are now being piloted in England: Evercare and Kaiser Permanente. Although pharmacists had little involvement in the early stages of the pilots, it is worth summarising what the two programmes aim to do in order to put into context the roles that pharmacists can play.

Evercare

Evercare is a health care improvement programme that is centred on the use of specialist nurses. Studies conducted in the US show that the Evercare programme results in a 50 per cent reduction in hospital admission rates compared with control patients. It also results in a reduction in the number of medicines a patient takes.

Evercare aims to delay the progression of chronic disease and prevent disease. It is all about keeping older people healthy for as long as possible. Its core principles are given in the Panel right. The Evercare care pathway starts off with the identification of “high-risk” older patients and an individual care plan is developed. Specialist nurses known as “advanced primary nurses” have a case load of patients whom they contact on a regular basis. The advanced primary nurses co-ordinate the care that the patient is receiving, eg, from other members of the primary health care team or from social services. They also monitor the patient and educate family and carers, particularly to spot changes in the patient’s condition. If increased support is needed, the advanced primary nurse organises this, including admission to a home on a temporary or long-term basis and co-ordinating care for any stays in hospital.

Pilots of the Evercare programme began in England last year (PJ, 3 May 2003, p608). Interim results of the pilot studies were published by the Department of Health two weeks ago. The pilots will continue until August and a full evaluation will be published early next year. Early findings are positive.

The interim report states that a critical element of the Evercare programme is preventing adverse drug reactions and polypharmacy. Part of its approach is to conduct regular medication reviews for elderly patients on high-risk drugs. Although this has been promoted as a role for nurses, it seems like an obvious area for pharmacists to be involved in.

One of the PCTs involved in the Evercare pilot is Luton PCT. Ian Winstanley, director of patient services, describes progress in the pilot in an article this week (see p618). Although Evercare is specifically nurse-led, Luton PCT has developed a role for pharmacists. “We decided to take on a pharmacist to look at medicines management issues. Then we asked ourselves why we were keeping the pharmacist at arm’s length from the process. We decided to develop the role of an advanced primary practitioner so the pharmacist is now undergoing the training that the advanced primary nurses did so that she can become a full member of the team,” Mr Winstanley explains. “These pharmacists need the same diagnostic and clinical skills as nurses so that they can talk the same language as the advanced primary nurses.” Other health professionals that might become advanced primary practitioners in addition to pharmacists are physiotherapists.

Evercare focuses on the vulnerable elderly population. “It is a good place to start but, unless younger age groups are tackled too, there will be wave upon wave of people becoming the vulnerable elderly. So we want to extend the initiative into other age groups,” says Mr Winstanley. “Pharmacist input will be needed at all stages. As soon as someone is diagnosed with a chronic disease they are likely to be on some form of medicine so pharmacists have a role right from the beginning.”

At the moment, Luton PCT has eight advanced primary nurses and one pharmacist training to be an advanced primary practitioner. This is likely to be extended to include other pharmacists and possibly pharmacy technicians. Training to become an advanced primary practitioner will take the form of a master’s degree course: this is currently being evaluated by the University of Luton.

Kaiser Permanente

Like Evercare, Kaiser Permanente aims to keep patients out of hospital. More care is delivered in the primary care setting and it is actively planned and managed. The six key principles of Kaiser Permanente are given in the Panel right. Patients are actively managed and an integrated approach to care is an essential part of the model. While Evercare is centralised around nurses, a more multidisciplinary approach is taken by Kaiser Permanente.

Patients are kept out of hospital in two ways: lower admission rates and shorter hospital stays. Kaiser Permanente’s philosophy is that hospital admission is an indicator that the systems of prevention and treatment in the community have failed. Early discharge is possible because home help services and nursing at home is used. For example, a patient admitted to hospital for a hip or knee replacement will spend 12 days in hospital under the NHS but only four days under the Kaiser system. In the US, Kaiser uses about one-third of the number of bed days as the NHS for causes such as asthma, bronchitis and strokes among people aged over 65 years.

One of the PCTs involved in the pilot of Kaiser Permanente in England is Sussex Downs and Weald PCT. Cheryl Clennett, pharmaceutical adviser for primary care, explains that the PCT has developed a “Promoting independent living strategy” as a result of its involvement in the Kaiser Permanente pilot. “Part of this strategy is using community pharmacists to provide medication reviews to help patients get the best out of their medicines, which should enable them to stay in their own homes for longer,” she says. A pilot of this service was undertaken by the PCT. Community pharmacists assessed whether medicines were suitable for patients, addressed medicines-related problems, such as whether the patient could take the medicine, and spoke to the patient’s GP about how to overcome any problems identified. “Finding community pharmacists who had sufficient time to take this on was problematic so we are waiting to hear what is in the new contract. We hope our service will form an additional service,” she says.

Ms Clennet adds: “There is a big role for pharmacists in conducting low-level medication reviews. The problems patients have with medicines often result from the patient not taking medicines, and these patients need to be identified.”

Three levels of care

Better chronic disease management can be offered in three levels of care (see Figure right). Mr Jackson comments that there are plenty of roles for pharmacists at all three levels. “At level three, when a case management approach is taken, pharmacists should be thinking about what pharmaceutical care is needed in this intensive situation. They will need to work closely with the case manager and, in situations where medicines are the predominant therapeutic intervention, a pharmacist could be the case manager,” he suggests. “The lower levels, involving disease management rather than case management, are likely to be more driven by guidelines, protocols or formularies. Pharmacists could have a role in drawing these up.” Use of supplementary prescribing could also provide opportunities for delivery of care within a disease management plan, he adds.

Pharmacists also have another role and that is in preventing chronic disease from happening in the first place through health promotion, Mr Jackson points out. Other areas that pharmacists could be involved in include managing minor ailments and supporting self-care. Hospital pharmacists will have a role in ensuring patients are discharged on appropriate medicines and that communication about patients’ medicines across the interface to colleagues in nursing homes or primary care is effective, he adds. “In the future, as diagnosis of diseases is moved more into primary care, pharmacists could have an increased role in screening, monitoring and diagnosis.”

Richard Lewis of the King’s Fund, which has studied the US systems, comments: “Pharmacists are a particularly important resource for patients who are further down the risk pyramid. The NHS must not, in the excitement over preventing hospital admissions, lose sight of keeping people well so they don’t need Evercare.” He adds that pharmacists can also play a useful role in preventing admissions through medication review and that perhaps the NHS should focus on this.

Mr Jackson stresses that, at the moment, chronic disease management is still in the development stage. “I personally see it as a major development for the whole of health care delivery and there are clearly opportunities for pharmacists. The important point now is how pharmacy positions itself so that it is thought about during the development process.”

The Royal Pharmaceutical Society has recognised this and is developing a programme of work examining roles that pharmacists can play. Sue Kilby, head of practice at the Society, comments: “The practice division will be working with other pharmacy organisations to map the work that has already been undertaken in this area and to identify what is still needed to enable pharmacists to become more involved in chronic disease management. If anyone is involved in any innovative work linked to chronic disease management then I will be pleased to hear from them.” She added: “For effective management of people with chronic disease, all sectors of pharmacy will need to work together.”

From a PCT perspective, Sue Carter, pharmaceutical adviser and head of prescribing and pharmacy at Ardur, Arun and Worthing PCT, comments: “Pharmacists need to be proactive in supporting patients’ medicine needs rather than waiting for something to go wrong. They should formalise their ideas about how to do this and take them to the professional executive committee or pharmaceutical adviser at their local PCT.” One suggestion is that pharmacists could operate a regular reminder and support service for patients likely to have problems with medicines, operating on a daily, weekly or monthly basis depending on patient need.

Good chronic disease management requires pharmacy input: treatment of nearly all chronic diseases involves medicines at some point and this is pharmacists’ area of expertise. Pharmacists have been largely left out of the pilots so far: now is the time to push for involvement.