Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities

NHS Improvement - Lung

NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Managing multi-morbidity in practice…what lessons can be learnt from the care ofpeople with COPD and co-morbidities?

Royal College ofGeneral Practitioners

The Royal College of GeneralPractitioners is a network ofmore than 45,000 familydoctors working to improvecare for patients. We work toencourage and maintain thehighest standards of generalmedical practice and act asthe voice of GPs oneducation, training, researchand clinical standards.

Endorsed by:

The Primary Care RespiratorySociety UK (PCRS-UK) is theUK-wide professional societydedicated to meeting thevision of ‘optimal respiratorycare for all’. Our mission isto give every member of theprimary care practice teamthe confidence to deliverquality respiratory care andimprove the quality of lifefor patients with respiratorydisease.

Education for Health is theworld's leading charity tofocus on the education ofhealth professionals as a keyfactor in improving patienthealth and quality of life.Our mission is to take action,educate people andtransform lives worldwide.We are a specialist providerof pioneering cardiovascularand respiratory educationand training courses,products and qualifications.

Royal College ofGeneral Practitioners

Contents

Introduction

Findings from sites• Survey method• Case study 1: Vauxhall Practice, Liverpool• Case study 2: Yellow Practice, Govan Health Centre, Glasgow• Case study 3: Leckhampton Surgery, Cheltenham• Case study 4: Woodbrook Medical Centre, Loughborough• Case study 5: Birtley Medical Group, Gateshead• Case study 6: Phoenix Medical Practice, Bradford

Key themes

Challenges

The way forward

Conclusion

Points to consider – developing structured reviews in practice

References

Acknowledgements

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Managing multi-morbidity in practice… whatlessons can be learnt from the care of people withCOPD and co-morbidities?

Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities?

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The case for managing multi-morbidityWith an increasingly ageingpopulation comes the challenge ofhow to deal with people with multi-morbidity (i.e the presence oftwo or more long term conditions inone person). Although theprevalence of multimorbid conditionsrises with age, a study of 314 Scottishgeneral practices showed absolutenumbers to be higher in the under 65age group.1 Furthermore, a Canadianstudy suggested that multimorbidityis the norm rather than the exceptionwith 69% patients aged 18-44having multimorbidity and 93%patients aged 45-64.2

People with multimorbidity are morelikely to die at an earlier age, morelikely to be admitted to hospital, havea poorer quality of life and are morelikely to be prescribed multiple drugswith consequent poor adherence.3

This suggests that there is scope toimprove management and outcomesfor these patients. Traditionally,disease management guidelines andpatient pathways have been devisedaround single disease entities. Thishas been encouraged by the demiseof the generalist in secondary careand the development of super-specialties. However, this disease-centred approach tends tounderestimate the effect ofpsychosocial factors influencing thepatient’s health and encourages thedevelopment of multiple treatmentregimes with increased potential foradverse drug interaction and poor adherence.

There is therefore an increasing needto organise care around the patientand not the disease, taking intoaccount his or her multiple physicaland psychosocial conditions. 4

A systematic review of interventionsfor people in primary care andcommunity settings which targetedmulti-morbidity indicated that therewas limited research evidenceavailable.3 However, the reviewindicated that interventions targetedeither at specific combinations ofcommon conditions, or specificproblems for patients with multipleconditions, may be more effective.

COPD and co-morbidity as an exemplarChronic obstructive pulmonarydisease (COPD) is a long-termcondition with a high prevalence (anestimated three million people inEngland)5 and with a high number ofco-morbidities. Table 1 shows theprevalence of co-morbidities ofsignificant long-term conditions inthe Scottish general practice multi-morbidity study, and shows thatpeople with COPD over the age of 65had a mean of 4.5 co-morbidconditions shown in the table.1 Assuch, the organisation of care forpeople with COPD and its co-morbidities has the potential to bean exemplar for the organisation ofcare for people with multi-morbiditiesin general.

Introduction

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Table 1: Co-morbidity of 10 common primary care conditions in 314 Scottish general practices1


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The Wagner chronic care model ofstructured care6 has identified fourkey elements which are likely to havea major impact on the quality andeffectiveness of care. These elements are:

• the promotion of self-management, • a comprehensive system to support clinical management,

• evidence-based support for decision making, and

• the use of clinical guidelines.

The 2010 NICE COPD Guidelines5

and international GOLD COPDGuidelines7 have increasinglyrecognised the need to assess co-morbidities when carrying out routineassessment of the patient with COPD.The Primary Care Respiratory Society-UK (PCRS-UK) have adapted the NICECOPD Guidelines for primary careand advocate a patient-centredapproach to COPD assessment andmanagement8 including theassessment of co-morbidities. Figure1 shows an algorithm summarisingthis patient-centered assessment.However the guidelines fall short ofhow to organise care for thesepatients.

This document summarises thelearning from a project to find outhow general practices in the UnitedKingdom have risen to the challengeof organizing chronic care of patientswith multimorbidity in practice, usingthe exemplar of COPD and its co-morbidities. It provides practicalexamples of approaches that havebeen tried, key learning points aboutwhat works and why, andsuggestions for the way forward.

This includes learning about planningahead, organisational issues,identifying the right patients andevaluating the impact of change. As such, it will be of help to all thoseinterested in improving the way careis organised in their own area forpatients with multi-morbidity.

Kevin Gruffydd-JonesGP Box Wiltshire , Respiratory LeadRCGP

Shoba PoduvalGP Islington, London and ClinicalSupport Fellow RCGP

Correspondence to Dr. Kevin Gruffydd-JonesEmail: [email protected]

SYMPTOMS?

Breathlessness

Short acting bronchodilators (betaagonist/anticholinergic)for relief of symptoms.

PERSISTENT SYMPTOMSSee pharmacotherapy Algorithm

PRODUCTIVE COUGHConsider mucolytics

FUNCTIONALLIMITATION?

MRC score > 3

Optimise pharmacotherapy(see algorithm)

Offer pulmonary rehabilitation

Screen for anxiety/depression

EXACERBATIONS?

Oral steroids/antibiotics/hospital

admissions

Optimise pharmacologic therapy

Discuss action plans including use of standby oral steroids and antibiotics

HYPOXIA?

Oxygen saturation < 92% at rest in air)

FEV-1 < 30% Predicted

Refer for oxygen assessments

HOLISTIC CARE

Check social support (e.g. carers and benefits)

(Treat co-morbidities).

Consider palliative therapy or secondary care referral for resistant symptoms

Refer to specialist palliative care teams forend-of-life care.

Source: Primary Care Respiratory Society UK, 2010

ALL PATIENTSSMOKING CESSATION ADVICEPATIENT EDUCATION/SELF MANAGEMENTASSESS AND TREAT COMORBIDITYASSESS BMI: DIETRY ADVICE >25

EXERCISE PROMOTIONPNEUMOCOCCAL VACCINATIONANNUAL INFLUENZA VACCINATIONSPECIALIST DIETRY REFERRAL IF BMI <20

Figure 1: Patient centred management of stable COPD in primary care8


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Survey methodA simple seven item questionnairewas developed by themultidisciplinary project committeewhich included questions aboutpractice demographics, how and whysystems for managing COPD patientswith co-morbidities were developed,the impact and any lessons learnt.

The questionnaire was uploaded toSurvey Monkey and publicisedamongst the networks of the RoyalCollege of General Practitioners, NHS Improvement, the Primary CareRespiratory Society UK and Education for Health. The survey wasopen from the 29 November 2012 to 8 February 2013.

Over thirty sites responded to the call for examples of effectivemanagement of multi-morbidityin COPD patients. Many of therespondents described systems formanaging COPD without co-morbidities and other practices did not wish to be contacted further.

Six case studies were chosen by theauthors which were thought torepresent the various approaches thatpractices used to tackle the problemof chronic disease management ofpeople with COPD and its co-morbidities.

Findings from sites


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Vauxhall Primary Health Care (VPHC)is an urban practice in Liverpool witha list size of 6,000 patients and ateam including GPs, practice nursesand a health care assistant.

A quality improvement project has beenrunning here for three to four years sincethe practice obtained funding fromneighbourhood cluster efficiency savingsfor 1.5 days/week of GP time to addressthe question:

How can we improve thecare of houseboundpatients with complexneeds registered atVPHC?”

What do they do?First of all the practice established aregister identifying patients at need,targeting first those who werehousebound with more than one Quality& Outcomes Framework (QoF)-registereddisease, multiple medications andunplanned admissions in the last year.

Patients were contacted by letter. All visitswere carried out by GPs who completedan assessment, involving a review of thenotes - including tidying up problem lists;medication review; care assessment(where possible involving carersthemselves); assessment of level of need(low, medium or high) and a documentedplan of care.

What did they achieve?Recorded data was audited andexperiences of staff, patients and carersreviewed. Results from initial dataavailable indicated a lack of impact onadmissions but a reduction in prescribing.Data showed that inappropriatemedication was stopped in 54 patientsout of 101 patients, due to a long-termview being taken about safety. Informal feedback was generally positive,especially from staff and carers (seetable 2

What are the challenges?With the next stages of this work beingplanned, the following challenges havebeen identified:• Who are the next most important targetgroups? Care home residents? New patients with multimorbidity? Patients with acute complex needs?

• Limits to funding due to competing priorities.

• With limited time available, the team will need to be clear about how best to use community matrons and GPs, for example focusing GP effort on the less straightforward cases such as those where diagnostic issues are dominant.

Key learning points• Identify your key ‘at-risk’ group that is most likely to benefit.

• Bear in mind the importance of holistic care - 63% of patients were found to have needs not met by existing chronic disease management or medication review processes and identifying these needs was difficult from routine collected data alone. Assessment by an experienced GP, with an ‘off-protocol’ patient-centered approach was found to be more useful.

• Make use of your community teams.• Work through how much clinical time is required and how you will find or fund it.

Vauxhall Primary Health Care, LiverpoolCase study 1:

For some, surprise/suspicion/concern that doctor has visitedfor review, unsolicited by patient.

From family/carers, support for opportunity for time for fullassessment/discussion especially re medication.

Positive impact of proactive review of patients, includingtidying up/rationalising medication.

Useful impact of reviewing the patient’s list of problems,medication reviews etc; protected time for visits for complexpatients valuable.

Patients/carers

Staff at carehomes

Staff at VPHC

Table 2: Feedback Summary

The consultation was an expert generalist needsassessment, based on the principle of a person-centredassessment of what was wrong and what interventionwas needed. In practice, much of the decision making related to demedicalisation... reducing the burden of care.

We are starting to make greater use of communitymatrons and also community pharmacy. Reserving GPsfor the less straightforward cases...what we are stillstruggling with is how to predict who those are. But oftenit is where the DIAGNOSTIC issues are dominant.Dr Joanne Reeve, Vauxhall Primary Health Care

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Yellow Practice is an inner citypractice based in a health centre withthree other Practices in Glasgow. Ithas a list size of 4,000 patients, fourGPs and two practice nurses.

What do they do?For three years the practice nurse hasorganised an ‘Annual Health ReviewClinic’ for patients with multiple chronicdiseases. Patients get a half hourappointment with the practice nurse,during which conditions includingdiabetes, heart disease, kidney disease,hypertension, heart failure, asthma,chronic obstructive pulmonary disease(COPD) and stroke can be reviewed. Ifmore time is needed a furtherappointment is booked, and if necessarya six monthly review can be arranged.

Patients are invited by letter (or textmessage if they have a mobile phone)and administrative staff are aware theyneed to make thirty minute appointmentsfor these reviews.

A second practice nurse is employed tocarry out annual health checks for thehousebound, and residents of carehomes. These patients are seen annually,six monthly or more often if required. No other community teams are involvedapart from the podiatry services that visitthe housebound diabetic patients athome and review diabetic patients whohave been identified as having high ormoderate diabetic foot disease.

Why did they do it?The practice nurse instigated this way ofmanaging patients with multiple chronicdisease because patients reported thatthey were tired of being invited fordifferent reviews at different clinicsseveral times a year.

What has been achieved?Patients have provided positive feedbackand comments on how much better theservice is now. Fewer appointments aretaken up as most of the conditionscovered involve similar measurements andlifestyle issues. Receptionists also find iteasier to book one appointment for theannual review.

The team has also found this system isbetter in relation to the practice’s QOFtargets and Locally Enhanced Service (LES)requirements, as everything is tackled atonce and it is easier to monitor targetsand results.

What were the challenges?• The lack of recall coding on the EMIS electronic records system.

• Evaluating cost benefits.

What were the key learning points?• Create a code in EMIS for chronic disease management review - it is time consuming to code everyone with that code but once done it is very useful.

• When to time the recall - the team at Yellow Practice tried making the patient’s annual review in the month of their birthday but for those who didn't respond straight away and were late it didn't work. So reviews are now booked according to when the patient was last seen. This took time and effort to organise but now works very well.

Yellow Practice, Govan Health Centre, GlasgowCase study 2:


Leckampton Surgery is an urbanPractice of 12,000 patients, ninedoctors, five Practice Nurses andthree HCA’s.

What do they do?The Leckhampton Surgery runs a ‘one-stop’ clinic for review of patients withmultiple chronic diseases. Each conditionis given 20 minutes plus extra time ifneeded. Patients are seen by a registerednurse who has skills and qualifications inchronic disease management, COPD,Asthma, Heart disease and diabetes. Sheis assisted by a health care assistant whocompletes all the clinical measurementsbeforehand such as spirometry, bloodsand diabetic foot checks, havingcompleted National VocationalQualification (NVQ) training. The nurse isa prescriber but GPs are involved wherenecessary. Staff training has been fundedby the practice and the pharmaceuticalindustry.

Patients are invited by letter and phonedor text messaged the week before toremind them of their appointment.

Housebound patients are visited by apractice nurse at request from a GP, or bythe GPs themselves. Community staff areasked to contribute to the review ofhousebound patients but it is found thatthey have very little time to spend onthese reviews and are not trained inchronic disease management of multipleconditions.

What did they achieve?Attendance is very good, and patientsatisfaction has increased due to onlyhaving to attend surgery once a year forreview. In addition, more appointmentsare available for the nursing team.

Leckhampton Surgery, CheltenhamCase study 3:

My advice is plan the clinic carefully. Work hard on thewording of the invite letter, keep it simple. Phonepatients to remind them of the appointment - it's a bigchunk of time if they do not attend.

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‘’Sharon Lamden, Lead Practice Nurse,

Leckhampton Surgery


Woodbrook Medical Centre is anurban 9,000 patient practice inLoughborough. There are six doctors,three nurses, a health care assistantand phlebotomist.

What do they do?Woodbrook planned to set up a one stoplong term conditions clinic. Theyidentified patients from the electronicrecords system with long term conditionssuch as chronic obstructive pulmonarydisease, hypertension and diabetes andrecorded the number of co-morbiditiesthe patient had. Figure 2 compares thenumber of selected co-morbidities seenwith each condition.

Disease severity was also stratifiedaccording to markers such as ForcedExpiratory Volume and Medical ResearchCouncil (MRC) Score for breathlessness. Patients with two or more co-morbiditieswould be taken through the processsummarized in the flowchart shown inFigure 3.

What were the challenges?The practice organized a three hour teammeeting with all lead clinicians where adetailed notes review of six patients wasundertaken. Although some savings wereprojected in terms of prescribingrationalization and reduction inappointments requested, they wereunable to progress further due to a lackof funding for the extra clinical time thatwas needed.

What were the key learning points?• Resources need to be identified to fund extra clinical time to get the project under way.

• A project manager is needed to create atimetable and to keep the process moving forward.

Woodbrook Medical Centre, LoughboroughCase study 4:

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The multiplicity of long term conditions borne by many of our patients demonstrates the difficulties involved in obtaining optimal outcomes for these conditions both individually and collectively; focusing on what the patient wishes to achieve will be more useful inapplying therapies rather than relying on singlecondition guidelines many of which will haveconflicting objectives and recommendations. The future lies in navigating these guidelines guided by the patient’s wishes and moving away from strictlytargeted control.

Figure 2 : Number of Co-morbidities with reference condition(on y axis) in Woodbrook Surgery, Loughborough.

Figure 3 : Flow chart of organisation of care for patientswith two or more co-morbidities in Woodbrook Surgery

‘

’

‘

’CKD

Epilepsy

Heart Failure

Stroke

COPD

Hypothyroidism

CHD

Diabetes

Asthma

Hypertension

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100

With main condition and 5 othersWith main condition and 4 othersWith main condition and 3 othersWith main condition and 2 othersWith main condition and 1 otherNo. of patients - just 1 condition

22362176369521

Hypertension

072860111504

Asthma

21443115194147

Diabetes

11145769173

CHD

19193266109

Hyperthyroidism

11223376758

COPD

21017375932

Stroke

272128184

HeartFailure

02141635

Epilepsy

1205795872

CKD

Dr Dermot Ryan, Woodbrook Surgery

Patient 2+co-morbidities

Identify bloodtests as requiredfor diseasemonitoring or QOF

Go to patientsummary toensure all co-morbiditieshave testsrequired

Send out invitation letter for bloodtests andquestionnairewith appointment

Perform bloodsand collect questionnaires

Perform questionnaires if not completed

Inform will be invited for review in three weeks

Notes for reviewby clinical pharmacist

Collection of bloodsand questionnaires

GP nurse specialistnote review

Review appointmentmade

Patient phoned 24hours prior

Follow up as needed

Forward diary for next review

Annual reviewwith actions

Reauthoriseprescriptions


Birtley Medical Centre is an 80%urban and 20% semi-rural practicewith a list size of approximately14,500 in Gateshead, County Durham.For 8-10 years the nursing team havebeen running a Better Health Clinicfor review of patients with chronicdiseases and co morbidities.

What do they do?Patients are seen in a Better Health Clinicappointment of thirty minutes with asenior practice nurse or nurse practitioner(depending on their co-morbidities). Allthe nurses who are involved have at leastdiploma training in the illnesses reviewed.

Patients are informed of the need fortheir review by a note on theirprescriptions. They are then asked tobook in for appropriate tests (such asbloods and spirometry) with a health careassistant and the Better Health Clinicappointment is made with them for oneto two weeks later. Making theappointment with the patient has beenhelpful in improving attendance rateswhich have been good.

Housebound patients are seen by GPs,practice nurses and community matronsas appropriate.

What did they achieve?Patients report greater satisfaction withthe new approach.

What were the challenges?• Training staff to an adequate level to meet the requirements of the clinic.

• Organising appointments so that enough time is allowed for review.

Key learning points• Investment in nurse recruitment and high quality training is essential, and it is important to ensure that staff complete enough regular consultations to keep up their skills.

• Allow enough time for the review by making sure the blood tests and spirometry are planned and executed in advance.

Birtley Medical Group, GatesheadCase study 5:

People have expressed their appreciation of the 'one stop shop' approach, particularly because there is a significant amount of interconnectedness.Liz Bryant, Nurse Practitioner, Birtley Medical Group

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Phoenix Medical Practice in Bradford,West Yorkshire, has a patient base of3,600 patients and has beenchampioning the concept of careplanning with patients with multi-morbidity under the directionof Dr. Shahid Ali. This has centred ondiabetes, but includes COPD andother long-term conditions.

What do they do?40% of the practice patients had a long-term condition, of which 25% had two ormore. These patients were invited toattend appointments for a care planningconsultation. Using an integrated longterm condition template the patients, intheir own words, record the issues thatare important to them and how theseimpact on self-caring and setting self-directed goals (e.g. giving up smoking).

Capturing this information ensures thegoals are relevant to the patient andmeans the patient can relate back tothem regularly. A follow up appointmentis made to assess progress against thesegoals.

What were the challenges?There is a need for practice meetings tochange the culture of chronic diseasemanagement towards patient –centredand supported self-management. There is also a need for training on themulti-disease templates.

What have they achieved?A health economic evaluation of 19patients using the care planning approachwas published in the Health ServiceJournal in 20109 This showed in areduction in health service contacts from529 to 246 in the 12 months pre andpost care planning, a reduction in outpatient contacts and a reduction inoverall health costs.

What were the key learning points?The experience of being in control andmaking independent decisions is highlymotivating for patients. The care planningapproach has been further piloted byother practices in West Yorkshire. Patientempowerment is being further enhancedby electronic sharing of data includinggoal setting via the internet or via smartphones.

Phoenix Medical Practice, BradfordCase study 6:


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Findings from the survey suggest thatwhilst practices have started toimplement systems which co-ordinatethe organisation of care of peoplewith COPD and its co-morbiditiesthese systems are in their infancy andthere has been little evidence offormal evaluation. This conclusionmust be tempered by the fact thatthere was a relatively low responserate to the request to complete thesurvey.

There may be several reasons for this: • Practices have not organised multi-morbid care around COPD. There is anecdotal evidence that practice systems have been built up with ischaemic heart disease or diabetes as the reference disease.

• General practices are under a lot of workload pressure at present, as evidenced by surveys from the British Medical Association and so response rates to surveys may not be optimum, especially when sent in a period around Christmas.

In spite of these limitations severalthemes emerged from those whoresponded to the survey:

1. MOTIVATION TO ORGANISEMULTLI-MORBID REVIEWSSome practices identified optimizingperformance under the Quality andOutcomes Framework (QOF) as themain purpose for developing asystem for managing patients withmultiple problems, due to theopportunity to complete all reviewsand templates at one consultation.

Some practices utilised Practice –Based Commissioning (PBC) or othersources of funding to develop ideasfor new systems, and others weremotivated by the need to increasepatient satisfaction with the way theirconditions are managed.

2. ORGANISATIONNine of the thirteen practices whoprovided additional information usedthe concept of a nurse-led ‘one stopclinic’ reviewing multiple conditionsin one consultation. Consultationstended to be structured aroundCOPD and ischaemic heart disease/heart failure rather than other co-morbidities. Most of the nurse-ledclinics involved a thirty minuteappointment with measurementssuch as spirometry and bloodsorganised in advance. One practiceused only fifteen minuteappointments but found thischallenging, especially as QoF dataneeded to be collected for allconditions using existing templates.

At one practice, a telehealth systemusing joint management plans issuedby the local Community PartnershipTrust enabled patients to self-managetheir symptoms over a trial period ofthree months.

A key to successful organisation wasprior planning by multidisciplinarymembers of the practice team

3. TELEHEALTH & TECHONOLOGYFew practices provided informationon using telehealth or technology tosupport management of co-morbidityin COPD or in multi-morbiditygenerally. Furlong Medical Practice inStoke on Trent, described howtelehealth can enhance patientengagement in managing their COPD(see box on page 14 for details).Nurses and patients have loved thesystem and it is being adopted morewidely and extended to otherconditions.

Successful implementation requiresengagement of the whole practiceteam in the initiative throughcommunication, incentives andtraining, and ensuring that there is aclear and consistent approach toidentifying and recruiting appropriatepatients to the service.

Key themes


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Telehealth in COPD managementFurlong Medical Practice, Stoke on Trent, adopted a ClinicalCommissioning Group (CCG) funded Florence mobile phone textingservice in January 2012 to enhance patient engagement in their COPDmanagement. They identified patients on the COPD register whoseclinical management could be improved and who could be given moreautonomy. Specific patient selection criteria were used, includingevidenceof one or more of the following:

• excessive use of inhalers• breathlessness on exertion • productive sputum• one or more exacerbations of COPD in last 12 months• attended practice frequently in previous year for respiratory reasons, having been prescribed two or more courses of antibiotics

• been admitted to hospital with exacerbation of COPD in previous year• attended Accident & Emergency, walk in centre, out of hours service with exacerbation of COPD/chest infection – in previous 12 months.

A joint management plan is agreed between patients and the practicenurse which is supported by a written leaflet. Patients take home apulse oximeter, thermometer, weighing scales and their rescuemedication. They then receive daily texts asking about sputum colourand oxygen saturations. Depending on sputum colour, they are asked ifthey feel unwell, and if so, are asked to take their temperature. If theirtemperature is >37.5C, they take rescue medication according to theiragreed joint management plan.

Clinicians monitor patients’ readings twice a week. There is a monthlytext enquiry about patient experience and the programme is run overthree months. There is an evaluation form at the end of the programmeand good patient self-care literature is given to patients to supplementtheir learning from the programme.

The practice believes telehealth enhances the care they deliver and offers patients an enormous advantage in understanding theircondition, thus making them more likely to comply with any agreedjoint management plan.

“Realise the potential of telehealth for enhancingquality of delivery of patient care and trial it inyour team.”

Professor Ruth Chambers, Furlong Medical Practice

4. PATIENT IDENTIFICATION AND RECRUITMENTMost practices identified patientsfrom their disease registers, with oneusing the patient’s birthday monthas the month of their review. Allpractices used written letters toinvite patients to their review, withone phoning patients a week beforetheir appointment to remind them.Some practices also used textmessaging for patients who hadmobile phones.

The wording of the letter or messagewas identified as an importantfactor, as it influenced patientanxiety and attendance rate. Onepractice described inviting patientswho were not engaging up to threetimes by letter, but if they did notwish to receive help they were notforced to take part but exempted forthat year.

5. STAFFThe majority of the practices ranclinics led by practice nurses. Somepractices had nurse prescribers tomodify medications but in othercases medications were reviewed by GPs after discussion with thepractice nurses.

Two practices also used junior nurses and health care assistants for spirometry, blood tests anddiabetic foot checks.


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Staff training was highlighted as animportant issue. Most practices hadnurses with qualifications in chronicdiseases. In some practices, nurseshad to be trained in chronic diseasemanagement or new nursesemployed. The cost of this wasbalanced against the savings innursing appointment time, due tomultiple problems being addressedin one appointment.

In terms of community andsecondary care involvement, onepractice mentioned good links withsecondary care and othersmentioned liaison with pharmacistsfor medication review and districtnurses and community matrons forthe care of housebound patients.

However, some found thatcommunity staff did not haveenough time to see all the patientsidentified or were not trained tomanage multiple problems.

Generally patients were referred tocommunity staff if needed but onepractice held fortnightly meetingswith the community matrons todiscuss housebound patients, as partof the requirement for the CCGLocally Enhanced Service (LES).

6. HOUSEBOUND PATIENTSThere was a range of care modelsused to manage houseboundpatients or patients with complexneeds. At one end of the spectrumthere was integrated team approachwith initial review by a communitymatron or GP, and subsequentsupport at home by the communityteam At the other end of thespectrum, the GP carried out thereviews of housebound patients.

7. EVALUATIONAlthough there was a paucity offormal evaluation, informal feedbackfrom practices found that resultingpatient and staff satisfaction washigh, mainly due to time saved dueto multiple problems beingaddressed at one consultation. Thisalso led to more nursingappointments becoming available.Some practices also reportedincreased adherence to medicationand reduced Accident andEmergency Attendances.


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Several practices highlighted trainingas one of the main challenges, sayinghigh quality training was vital forsuccess of the scheme to ensure staffwere skilled in assessing andmanaging multi-morbidity.

Careful organisation and timemanagement were also essential,with enough time needing to begiven to appointments and allmeasurements such as bloods beingtaken beforehand.

Practical resources were anotherchallenge. One practice needed tomodify their invite letter to optimisepatient attendance and found theylacked an appropriate template forentering all relevant data.

Funding was the other mainchallenge that many practices cited.This was generally funding fortraining or extra clinical time, withevidence of evaluation and successfuloutcomes needed before furtherfunding could be provided.

Challenges


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The move away from a disease-centric model of care towards apatient-centred multimorbid systemraises several challenges for thoseworking to deliver structured care.

The current Quality and OutcomesFramework is a major driver instructuring chronic care in generalpractice, but tends to be disease-specific. As such, care needsto be taken to ensure it does notbecome a potential barrier todelivering effective integrated care inconjunction with community teams.Financing of schemes may be moreappropriately made by using leverssuch as Commissioning for Qualityand Innovation (CQUIN)13 paymentsacross a locality to encourage a moreintegrated approach to care.

There is a major need to developmultimorbid disease managementtemplates which are geared to theindividual patient and which take intoaccount common psychosocial factorssuch as depression and the needs ofcarers. Looking to the future there isalso a need to look at new ways ofdeveloping patient pathways andguidelines away from the currentdisease specific models to moregeneric approaches around patientproblems e.g ‘disability orbreathlessness’.

The NHS has organised chronic carearound a long term conditionsmodel4, shown diagrammatically infigure 4 below. In recent yearsintegrated care models haveconcentrated on patients at level 2and level 3 who are high risk or with‘complex needs’. However, with theincreased realization that patientswith multi morbidity are the normrather than the exception, there isalso an increased need for integratedworking at a practice level with level 1 patients. Examples of this arethe involvement of CommunityPharmacists to minimizepolypharmacy and attached practicesocial workers to help deal withpsychosocial problems.

The way forward

Figure 4: NHS Long-Term Conditions Model5

LEVEL 3:High complexity

Casemanagement

LEVEL 2:High risk

Disease/case management

LEVEL 1:70-80% of LTC population

Self care support/management


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Proactive chronic care of patientswith COPD and its co-morbiditiesprovides an exemplar for chronic careof patients with multimorbidity ingeneral practice. Examples of suchcare are limited but the final sectionof this document uses the keylearning points from this survey togive advice to general practicesplanning to offer structured chroniccare for people with multimorbidities.

Learning from those sites whoresponded to the survey suggeststhere is a need for multimorbiddisease management templates andcare pathways, and that integratedworking with community teams,including pharmacists, can improveoutcomes, with the potential toreduce overall consultation times,increase patient satisfaction, reducepolypharmacy and reduce hospitaladmissions.

Conclusion

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Points to consider when organising structuredreviews for patients with COPD and co-morbidities in primary care

• What are the benefits to the practice and to the patients, carers or family? e.g less consultation time, fewer visits for the patient, achieving the objectives of a locally enhanced scheme.

• What are the likely financial consequences?• Consider canvassing CCG or local health group to provide finance/support for groups of practices under CQUIN/LES and to support work across boundaries.

• Identify who is, could or should be involved in the organisation of care (e.g practice staff, community staff, pharmacist , social services, patients and carers)

• Involve these stakeholders in the planning of care to increase understanding or what currently happens, what could happen and to encourage motivation for the service to succeed.

• Which co-morbidities will be included? Which are most common? • Are higher risk patients to be identified and how will this be done (e.g COPD patients with two or more exacerbations in the last year)?

• How will patients receive invitations and be reminded to attend appointments?• How will checks be organised? e.g number of appointments per patient, duration of appointmentsand which practice staff will be involved.

• How much time is currently available and how is it used? How could it be used differently? Do you need any extra time?

• What will happen in each appointment?• Do the staff have sufficient training in the co-morbid conditions to be reviewed?• How will the data be recorded? Are the disease templates sufficient for purpose? • Are practice management protocols sufficient for purpose?• Consider use of telehealth for higher risk patients. How could this enhance care?

• How will care of patients be integrated with other members of the community team (and secondary care)? e.g pharmacist, social services, mental health services and specialist community teams.

• How will the needs of patients deemed high risk and /or housebound be met by the community/practice team?

• Will this satisfy the requirements of the QOF?

How will you evaluate success? • Baseline and improvement - Where are you starting from? What do you need to measure as a baseline so that you can tell whether your changes are making a difference? What will you need to demonstrate to others to ensure support for the change?

• Patient feedback – what do you want to know? How will you find out? What do patients think of the current service? What do they suggest might work better? How will you measure a change in their experience or satisfaction?

• Consultation time – how much time is needed? How much time overall is needed, before and after? Who currently does what?

• Costs and benefits – can you demonstrate reduced hospital admissions, reduced exacerbations, prescribing and adherence, QOF impact, use of urgent appointments or A&E, total cost of time and resources required, reduced duplication of tests or appointments?

• Improved Quality of Life - using generic questionnaires such as Euroqol (EQ5-D)10 or disease specific questionnaires e.g COPD Assessment Test (CAT)11

• Increased patient enablement - using Patient Enablement Instrument.12

BE CLEAR WHY YOUARE REORGANISINGCARE

PRIOR PLANNING

IDENTIFICATION OFPATIENTS

ORGANISATION

INTEGRATED CARE

EVALUATION

KEY POINTS


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Find resources such as First steps towards quality improvement: A simple guide to improvingservices to help you plan, deliver and evaluate your project at www.improvement.nhs.uk

QUESTIONS TO CONSIDER


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References

1. Barnett K, Mercer SV et al. Epidemiology of multimorbidity and implications for health care, research and medical education. The Lancet 360 9836: 38. 37-43.

2. Fortin M, Soubhi H, Hudon C, Bayliss EA and MvD Akker. Multimorbidity’s many challenges. British Medical Journal 2007; 334 (7602): 1016-1017.

3. Susan M Smith. Managing Patients with multimorbidity: systematic review of interventions in primary care and community settings. British Medical Journal 2012 292: 345 e5205

4. Kadam U. Redesigning the general practice consultation to improve care for patients with multimorbidity, British Medical Journal. 2012 Sep 17;345:e6202

5. National Clinical Guideline Centre. (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre. http://guidance.nice.org.uk/CG101

6. Wagner EH, Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1) 2-4

7. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Pulmonary Disease(2011) www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html

8. Diagnosis and Management of COPD in Primary Care. Primary Care Respiratory Society, UKwww.pcrs-uk.org

9. Shahid Ali . When a care plan comes together .Health Service Journal 9.12.2010 p20

10. Euroqol(EQ-5D) questionnaire www.euroqol.org

11. COPD Assessment Test. www.catestonline.org

12. Howie, J. G., Heaney, D. J., Maxwell, M, & Walker, J. J. (1998). A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Family Practice, 15(2), 165-171.

13. Commissioning for Quality and Innovation (CQUIN) payments. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443

14. An Outcomes Strategy for COPD and asthma in England. 2011 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128428.pdf


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Thanks to:

The Project Committee of:

Catherine Blackaby NHS Improvement Phil Duncan NHS Improvement Rigoberto Pizarro-Duhart CIRC RCGPChristine Loveridge COPD/Spirometry Clinical Lead, Education for Health, WarwickDermot Ryan GP Principal LoughboroughMatt Kearney Department of Health Respiratory TeamSara Askew Primary Care Respiratory Society UK.

The many practices who replied to the survey request, in particular Dr Joanne Reeve(Vauxhall Primary Health Care), Sharon Lamden (Leckhampton Surgery), Sarah Everett(Yellow Practice), Dr Dermot Ryan (Woodbrook Surgery), Liz Bryant and Deborah Dews(Birtley Medical Group), Professor Ruth Chambers (Furlong Medical Practice) and DrShahid Ali (Phoenix Medical Practice) for their contribution to the case studies.

Chris Gush and Fiona Fordham from CIRC for administrative support.

To Novartis Pharmaceuticals for providing financial support via an unrestricted educational grant.

Acknowledgements


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NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector

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Managing multi-morbidity in practice… what lessons can be learnt from the care of people with COPD and co-morbidities

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