Self Management, Multimorbidity, Shared Decision Making and Care Planning with People who have Long Term Conditions Nigel Mathers Professor of Primary Medical Care, University of Sheffield Vice Chair, Royal College of General Practitioners South Yorkshire GPSTP June 2013 Academic Unit of Primary Medical Care
Academic Unit of Primary Medical Care. Self Management, Multimorbidity, Shared Decision Making and Care Planning with People who have Long Term Conditions Nigel Mathers Professor of Primary Medical Care, University of Sheffield Vice Chair, Royal College of General Practitioners. - PowerPoint PPT Presentation
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Self Management, Multimorbidity, Shared Decision Making and Care Planning with People who have
Long Term Conditions
Nigel Mathers
Professor of Primary Medical Care, University of SheffieldVice Chair, Royal College of General Practitioners
South Yorkshire GPSTP
June 2013
Academic Unit of Primary
Medical Care
2
Long Term Conditions and Personalisation of Care
Background
”the ageing population and the increased prevalence of chronic diseases require a strong reorientation away from the current emphasis
on acute and episodic care towards prevention, self care, and care that is well-coordinated and
integrated.”
The King’s Fund, 2011
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
1. Long Term Conditions:
• 15.4m people in England have one or more long term conditions (LTCs) • Utilisation of health services is high amongst the LTC group – they account for 30% of the population, but 70% of NHS spending (c. £70bn)• The number of people with multiple conditions is projected to increase and this will put pressure on NHS budgets • LTCs are strongly linked to health and economic inequalities• While the majority of people with LTCs are elderly by no means all
The person who lives with an LTC:
Day to day management is self management
Our grossly underutilized workforce: [people who live with LTCs]
2. Self management; many tasks, many challenges
The domains of self management:
My condition (Biological)
What I do(Social / Behavioural)
The way I feel (Psychological)
3. Patient Activation = knowledge, skills and confidence to manage one’s own health and healthcare
Knowledge(Biological)
Skills(Social / Behavioural)
Confidence(Psychological)
Strategies to support people on their ‘journey of activation’
Public services face unprecedented challenges
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0% 20% 40% 60% 80% 100%
Depression
Schizophrenia/bipolar
Anxiety
Dementia
Asthma
Epilepsy
Cancer
Hypertension
COPD
Diabetes
Painful condition
Coronary heart disease
Atrial fibrillation
Stroke/TIA
Heart failure
Percentage of patients with each condition who have other conditionsThis condition only This condition + 1 other + 2 others + 3 or more others
The commonest long term condition is:
Multiple long term conditions
11
Shared Decision Making, Care Planning and the use of Patient Decision Aids
4. Multimorbidity and Long Term Conditions:
The Picture in Scotland• Clinical data from 310 Scottish general practices for 1,754,133 registered patients was provided by the Primary Care Clinical Informatics Unit (“PCCIU data”)
• Clinical data from 40 Scottish general practices linked to hospital admissions data (“ISD and PCCIU data”)
•Stewart Mercer, Professor of Primary Care Research, University of Glasgow: SSPC National Lead for Multimorbidity Research [email protected]•Bruce Guthrie, Professor of Primary Care Medicine, University of Dundee: Living Well with Multimorbidity Epidemiology work-stream lead [email protected] •Sally Wyke, Professor of Interdisciplinary Research, University of Glasgow: [email protected]
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Multimorbidity and Long Term Conditions
Shared Decision Making, Care Planning and the use of Patient Decision Aids
How they relate
14
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Multimorbidity and Hospital Admissions
3 59 14 21
3447
6485
100
151
20
3151
74
115
151
200
242
318
342
479
0
100
200
300
400
500
600
0 1 2 3 4 5 6 7 8 9 10+
Ann
ual a
dmis
sion
rate
per
100
0 pa
tien
ts
No of conditions
Potentially preventable admission
Other emergency admissions
15
Shared Decision Making, Care Planning and the use of Patient Decision Aids
5. Shared Decision Making
Shared decision Making is ‘a process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences.
It involves the provision of evidence-based information about options, outcomes and uncertainties, together with decision support counselling and a system for recording and implementing patients’ informed preferences.’
Coulter A and Collins A. 2011. Making shared decision-making a reality: no decision about me, without me [pdf] London. The Kings Fund. Available at http://www.kingsfund.org.uk/publications/nhs_decisionmaking.html [Accessed 25 April 2012]
17
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Shared Decision Making
NHS patient Surveys (2002-9)
46-49% patients want more involvement in treatmentdecisions
20101 in 3 patients in Primary Care1 in 2 patients in Hospital
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Benefits of Shared Decision Making
Better ConsultationsClearer Risk CommunicationImproved Health LiteracyMore Appropriate DecisionsFewer Unwanted TreatmentsHealthier LifestylesImproved Confidence and Self-efficacySafer CareReduced CostsBetter Health Outcomes
19
Shared Decision Making, Care Planning and the use of Patient Decision Aids
6. What are Patient Decision Aids (PDAs)?
• Evidence base for treatment options• Clarification of people’s values• Systematic guidance to inform decisions
Shared Decision Making, Care Planning and the use of Patient Decision Aids
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Shared Decision Making, Care Planning and the use of Patient Decision Aids
The PANDAs decision aid:• For doctors and nurses in General Practice• For people with Type 2 diabetes (T2DM) who are making treatment choices
Purpose of the study:To determine the clinical effectiveness of the PANDAs decision aid.
Primary Research Question:
“Does the use of the PANDAs decision aid improve decision quality in patients with T2DM who are making decisions whether or not to start insulin in General Practice?”
22
Shared Decision Making, Care Planning and the use of Patient Decision Aids
METHODS [1]
Design: A cluster randomised controlled trial
Intervention:• Brief training of clinicians• Pre-consultation familiarisation with the PDA • Use of PDA by patients and clinicians in the consultation
Control: • Usual care (no PDA)
Participants:175 people with T2DM from 49 General Practices randomised into intervention (n=25) and control (n=24) groups.
23
Shared Decision Making, Care Planning and the use of Patient Decision Aids
METHODS [2]
Inclusion criteria:
Practices:• >4 partners• List size >7,000• T2DM > 1% of Practice population
Patients:• People with T2DM (age >21) taking at least 2 oral glucose-lowering drugs at maximum tolerated dose• Most recent HbA1c >7.4% (>57 mmols/mol) or • Advised in preceding 6 months to add or consider changing to insulin
24
Shared Decision Making, Care Planning and the use of Patient Decision Aids
METHODS [3]Outcome measures and follow-up:
Primary outcome measure: • Decisional conflict based on the Decisional Conflict Scale score (indicator of decision quality)
Secondary outcome measures• Knowledge: which treatment option most effective in reducing blood glucose and diabetic complications?• Realistic expectations: self-report of chances of experiencing hypoglycaemia, gaining weight and developing complications• Preference option: preferred treatment of initiating insulin, adhering more to diabetes advice, or making no change• Participation in decision making (Control Preference Scale)• Regret: for decision made (Regret Scale)
25
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Intervention Control
Number of Practices 25 24
List Size 7,510 (3,129-20,900) 7,325 (1,974-13,500)
Shared Decision Making, Care Planning and the use of Patient Decision Aids
33
Long Term Conditions and Personalisation of Care
The Richmond Group of Charities
Principles:
1. Co-ordinated care
Desired outcomes: people feel that the care they receive is seamless because it is organised around them and their needs.
34
Long Term Conditions and Personalisation of Care
The Richmond Group of Charities
Principles:
2. Patients engaged in decisions about their care
Desired outcomes: all patients and carers can take anactive role in decisions about their care and treatmentbecause they are given the right opportunities, information and support.
35
Long Term Conditions and Personalisation of Care
The Richmond Group of Charities
Principles:
3. Supported self-management
Desired outcomes: people with long term conditions canmanage their condition appropriately because they havethe right opportunities, resources and support.
36
Shared Decision Making, Care Planning and the use of Patient Decision Aids
7. What is Care Planning?
1.Prepared pro-active Practice team
2.Informed engagement by people in their own care
3.Partnership working between Doctors/Nurses [HCPs] and people with Long Term Conditions [LTCs]
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
‘The House’ IT: Clinical record of care planning
& able to feed data into commissioning
Consultation skills/attitude
Integrated, multi-disciplinary team &
expertise
Senior buy-in & local champions to
support & role model
Emotional & psychological
support
Information/ structured education
‘Prepared’ for consultation
Identify and fulfill needs
Procured time for consultations, training and IT
Quality assure and measure
38
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Care Planning: the Sheffield experience (Stephenson, 2013)
Care fragmentation
R3
Shared Decision Making, Care Planning and the use of Patient Decision Aids
RCGP Care Planning Programme:
The Vision:
A joint strategic approach to health improvement based on the concerted implementation of care planning in general practice, within the context of multimorbidity,
and in partnership with a range of disease specific organisations; covering, for example, cardiovascular
conditions, respiratory and musculo-skeletal conditions and cancer.
42
Long Term Conditions and Personalisation of Care
The RCGP Care Planning Programme
Aims:
• To embed care planning into the ‘core business’ of General Practice
• To incorporate the development of care planning skills into the GP training curriculum and facilitate other educational initiatives for established GPs.
43
Long Term Conditions and Personalisation of CareThe RCGP Care Planning Programme:
Objectives:
• Communities of Practice ‘Natural Laboratories’Leadership facilitationActive Championing (“diffusion of innovation”)Primary Healthcare Team involvement
Service redesign/delivery models
• Learning and training resources (GP curriculum)
• Improvement research (evaluation)
• Development of IT/Metrics
• Communication strategy
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
8. Practice Variation
Understanding variation: the bad and the good. Mulley, 2011
Bad Variation (care not evidence-based)
•Poor research professional uncertainty
•Poor knowledge professional ignorance
JAMA, 1988
Good Variation (care is patient-centered)
•Clinical differences among patients
•Personal differences among patients
If all variation were bad, it would be easy to stop it. What is difficult is reducing the bad variation while keeping the good.
Shared Decision Making, Care Planning and the use of Patient Decision Aids
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Practice variation: when there is little or no evidence
• When to order a diagnostic test…?
• How often to see a patient with chronic disease…?
• When to admit a patient to a hospital…?
• When to admit a patient to intensive care…?
• How long a patient should stay in the hospital…?
Shared Decision Making, Care Planning and the use of Patient Decision Aids
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Variation: decreasing the bad and increasing the goodMulley, 2011
Decreasing bad variation (making care evidence-based)
•Improve knowledge management
•Improve communication
•No avoidable ignoranceIncreasing good variation (making care patient-centered)
•Recognize clinical differences among patients
•Honor personal differences among patients
The only efficient way to reduce overuse, underuse, and misuse of care
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Patient ‘Empowerment’ [Personalisation of Care]
Long Term Conditions and Multimorbidity
Shared Decision Making (Patient Activation)
Use of Patient Decision Aids
Care Planning
Practice Variation
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Long Term Conditions and Personalisation of Care
It’s time for change!
Thank You
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Questions?
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Clinical Practice variation
J Allison Glover, 1874-1963
1938:
•10-fold variation in tonsillectomy
•8-fold risk of death with surgical treatment
•The response:•“…these strange bare facts of incidence…”•“… tendency for the operation to be performed for no particular reason and no particular result.”•“…sad to reflect that many of the anesthetic deaths… were due to unnecessary operations.”
Shared Decision Making, Care Planning and the use of Patient Decision Aids
7
John E. Wennberg, 1973
Shared Decision Making, Care Planning and the use of Patient Decision Aids
•17-fold variation in tonsillectomy
•6-fold variation in hysterectomy
•4-fold variation in prostatectomy
•“The need for assessing outcome of common medical practices”
•“Professional uncertainty and the problem of supplier-induced demand”
Clinical practice variation: it’s rediscovery by Wennberg
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
The PANDAs Decision Aid contains the following information in line with the International Patient Decision Aid Standards criteria:
1. Information about insulin and other treatment optionsReasons for starting insulinThe procedure for insulin injectionCommon concerns about insulinTreatment options: Make no change; lifestyle
modification; insulin therapy
2. Presents probabilities of outcomesThe advantages and disadvantages of each option
are described in words, numbers and pictures (‘smiley faces’)
3. Patient value clarificationsA list of patients’ values about the advantages and
disadvantages of insulin therapy
4. Structured guidance
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Content of the PANDAs decision aid
Shared Decision Making, Care Planning and the use of Patient Decision Aids
• Control Preference Scale (CPS)5 item scale: 2 items active role, 1 item shared role, 2 Items passive
role
• Regret Scale5 item scale: measures distress or remorse after a healthcare
decision
57
Shared Decision Making, Care Planning and the use of Patient Decision Aids
METHODS [8]
Statistical Analysis
• Using total DCS score as primary outcome: total number of participants 86 and total cluster size 17• Outcome variables treated as continuous• Multiple regressions with generalised estimating equations (GEE) and exchangeable correlation to allow for clustering• Multiple logistic regression with GEE was used for binary outcomes in the secondary analysis• Analysis according to intention to treat principle
58
Subscore Intervention Control Mean differenceunadjusted
Mean difference adjusted*
95% CIp value
Uncertainty 20.1 (16.6) 29.4 (20.8)
-9.29 -8.72 -14.9 to -2.53 p=0.006
Informed 18.1 (13.3) 26.0 (16.6)
-7.65 -8.69 -13.3 to -4.10 p<0.001
Values Clarity 16.7 (13.9) 26.7 (18.2)
-9.74 -9.84 -14.8 to -4.84p<0.001
Support 17.4 (13.1) 20.8 (15.3)
-3.41 -3.66 -8.58 to 1.25p=0.144
Effective Decision
16.1 (14.4) 23.3 (15.2)
-9.70 -9.80 -16.8 to 2.75p=0.006
Total Score 17.4 (12.6) 25.2 (14.9)
-7.67 -7.72 -12.5 to –2.97p<0.001
* adjusted for age, education and gender
Comparison of decisional conflict scores between the intervention and control groups (0=no decisional conflict, 100=maximum decisional conflict).
59
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Intervention Decision Aid
ControlUsual Care
UnadjustedOdds Ratio
Adjusted+ Odds Ratio (95% CI)
ICC p value
Knowledge
Number 95 80
Which choice has the greatest chance of lowering your blood sugar?
49(51.6%)
23(28.8%)
2.63 1.31 (1.14 to 1.50)
0.071 <0.001
Which choice has the greatest chance of lowering your complications?
29(30.5%)
23(28.8%)
1.09 1.20 (0.07 to 19.05) 0.202 0.90
Realistic expectations
If you take insulin, about how many times might you experience ‘hypos’ in a year?
77/95(81.0%)
4/75(5.2%)
77 ^ - <0.001*
If you take insulin, about how much more weight might you gain in a year?
67/95 (70.5%) 4/75 (5.3%) 42.5 - <0.001*
Out of 100 people like you who take insulin, how many may get complications in five years?
25/95 (26.3%) 4/80 (5%) ^ - <0.001*
+ adjusted for clustering, insulin initiation, age, gender and education level ^ Numbers answering correctly in the control group were too few to control for clustering.* Chi-squared p value
Secondary outcomes: Knowledge and realistic expectations (Questions answered correctly)
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Intervention Control Mean difference unadjusted
Mean difference adjusted*
p value
Regret Score 44.63 44.57 0.06 0.22(-2.48 to
2.93)
0.872
Persistence with chosen option
68.1% 56.3% 1.65† 1.17^
(1.00 to 1.36)
0.041
* adjusted for age, education, gender, baseline HbA1c, insulin status and clustering†Crude odds ratio ^Adjusted odds ratio
Comparison of the decision Regret Score and persistence with chosen option between the intervention and usual care groups after six months
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Shared Decision Making, Care Planning and the use of Patient Decision Aids
Acknowledgements:
Funding body: National Institute for Health Research (NIHR), Research for Patient Benefit Programme UK [PB-PG-0906-11248]
NIHR National Trials Register: 14842077
Sheffield Health and Social Care NHS Foundation Trust
Ethics permission: North Sheffield Research Ethics Committee (07/Q2308/53)
Expert specialist advice: Professor Simon Heller
Members of the PANDAs Advisory Group
Members of the Sheffield Diabetes UK Group
ALL DOCTORS, NURSES AND PEOPLE WITH DIABETES WHO PARTICIPATED IN THE PANDAs TRIAL
R1
Shared Decision Making, Care Planning and the use of Patient Decision Aids
R2
Shared Decision Making, Care Planning and the use of Patient Decision Aids
SINGLE DISEASE SPECIFIC SOLUTIONS WILL NOT WORK
R5
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Decision plane showing the distribution of simple consent, informed consent, and shared decision making within 4 types of medical decisions
Quadrant A: high risk, high certaintyConsent type: InformedShared decision making: absentInteraction: intermediate, enough for an adequately informed decisionExample: laparotomy for gunshot wound of abdomen
Quadrant B: high risk, low certaintyConsent type: InformedShared decision making: presentInteraction: extensive, including discussion of patient values, preferences, hopes and fearsExample: mastectomy or lumpectomy plus radiation for early breast cancer
Quadrant C: low risk, high certaintyConsent type: simpleShared decision making: absentInteraction: minimal or noneExample: lower diruetic dose for patient with low serum potassium level
Quadrant D: low risk, low certaintyConsent type: simpleShared decision making: presentInteraction: intermediateExample: lifestyle changes vs. medication for lyperlipidemia
Zone of informed consent
Zone of shared decision making
Combined zone
Certain(1 clear best choice)
Certainty Uncertain>2 alternatives
Ris
kH
Igh
Lo
w
R6
RCGP Care Planning Programme
Communities of Practice – Tasks
• Redesign the condition-specific pathway• Contribute to evaluation• Collect feedback and use agreed metrics• Develop local systems of project management• Medical ‘musts’ in multimorbidity• Determine resource use within/between Practices• Use agreed IT• Participate in learning sets• Develop and share local commissioning mechanisms
Shared decision making, care planning and the use of patient decision aids
67
Long Term Conditions and Personalisation of Care
Context
• 15.4m people in England have one or more long term conditions (LTCs) • Utilisation of health services is high amongst the LTC group – they account for 30% of the population, but 70% of NHS spending (c. £70bn)• The number of people with multiple conditions is projected to increase and this will put pressure on NHS budgets • LTCs are strongly linked to health and economic inequalities• While the majority are elderly by no means all
69
Long Term Conditions and Personalisation of Care
Multimorbidity and Long Term Conditions
The Picture in Scotland• Clinical data from 310 Scottish general practices for 1,754,133 registered patients was provided by the Primary Care Clinical Informatics Unit (“PCCIU data”)
• Or clinical data from 40 Scottish general practices linked to hospital admissions data (“ISD and PCCIU data”)
•Stewart Mercer, Professor of Primary Care Research, University of Glasgow: SSPC National Lead for Multimorbidity Research [email protected]•Bruce Guthrie, Professor of Primary Care Medicine, University of Dundee: Living Well with Multimorbidity Epidemiology work-stream lead [email protected] •Sally Wyke, Professor of Interdisciplinary Research, University of Glasgow: [email protected]
Shared Decision Making, Care Planning and the use of Patient Decision Aids
Wagner, 2004
73
Long Term Conditions and Personalisation of Care
‘The House’ IT: Clinical record of care planning
& able to feed data into commissioning
Consultation skills/attitude
Integrated, multi-disciplinary team &
expertise
Senior buy-in & local champions to
support & role model
Emotional & psychological
support
Information/ structured education
‘Prepared’ for consultation
Identify and fulfill needs
Procured time for consultations, training and IT
Quality assure and measure
74
Long Term Conditions and Personalisation of Care
Care Planning: the Sheffield experience (Stephenson, 2013)
75
Long Term Conditions and Personalisation of Care
NHS Funding
arctic’ scenario: real funding cuts (-2 per cent for first three years, -1 per cent for second three years) ‘cold’ scenario: 0 per cent real growth in six years ‘tepid’ scenario: real increase (+2 per cent for first 3 years, then +3 per cent for the next three years).
Appleby J, Crawford R, Emmerson C. (2009) How cold will it be? http://www.kingsfund.org.uk/research/publications/ how_cold_will_it_be_html (Last accessed on 11 October 2009).
Risk profiling and stratification of risk Integrated community teams with single lead professional contact for Care Planning Transferring knowledge and control back to the patient
Enabled by Change in tariff moving to “A Year of Care”
Supported by Futures Forum report on Integration
77
Long Term Conditions and Personalisation of Care
The Richmond Group of Charities
Principles:
1. Co-ordinated care
Desired outcomes: people feel that the care they receive is seamless because it is organised around them and their needs.
78
Long Term Conditions and Personalisation of Care
RCGP Care Planning Programme:
The Vision:
A joint strategic approach to health improvement based on the concerted implementation of care planning in general practice, within the context of multimorbidity,
and in partnership with a range of disease specific organisations; covering, for example, cardiovascular
conditions, respiratory and musculo-skeletal conditions and cancer.
79
Long Term Conditions and Personalisation of Care
The Richmond Group of Charities
Principles:
2. Patients engaged in decisions about their care
Desired outcomes: all patients and carers can take anactive role in decisions about their care and treatmentbecause they are given the right opportunities, information and support.
80
Long Term Conditions and Personalisation of Care
The Richmond Group of Charities
Principles:
3. Supported self-management
Desired outcomes: people with long term conditions canmanage their condition appropriately because they havethe right opportunities, resources and support.
81
Long Term Conditions and Personalisation of Care
RCGP Care Planning Programme
Communities of Practice – Tasks
• Redesign the condition-specific pathway• Contribute to evaluation• Collect feedback and use agreed metrics• Develop local systems of project management• Medical ‘musts’ in multimorbidity• Determine resource use within/between Practices• Use agreed IT• Participate in learning sets• Develop and share local commissioning mechanisms
82
Long Term Conditions and Personalisation of Care
RCGP Care Planning Consortium:
• British Heart Foundation• British Lung Foundation• Macmillan Cancer Support• Arthritis Research UK• King’s Fund• Health Foundation• Primary Care Rheumatology Society• Diabetes UK• RCGP
83
Long Term Conditions and Personalisation of Care
SINGLE DISEASE SPECIFIC SOLUTIONS WILL NOT WORK
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Long Term Conditions and Personalisation of Care
How they relate
85
Long Term Conditions and Personalisation of Care
Principles:
1.Co-ordinated Care
2.Patients engaged in decisions about their care
3. Supported self-management
86
Shared decision making, care planning and the use of patient decision aids
The RCGP Care Planning Programme
Aims:
• To embed care planning into the ‘core business’ of General Practice
• To incorporate the development of care planning skills into the GP training curriculum and facilitate other educational initiatives for established GPs.
87
Shared decision making, care planning and the use of patient decision aids
The RCGP Care Planning Programme
Objectives:
1. Build communities of Practice (‘Natural Laboratories’)• Leadership facilitation• Active Championing (“diffusion of innovation”)• Primary Healthcare Team involvement• Service redesign/delivery models
2. Develop a central reference (evaluation) group
• Learning and training resources (GP curriculum)• Improvement research (evaluation)• Development of IT/Metrics• Communication strategy
88
Shared decision making, care planning and the use of patient decision aids
RCGP Care Planning Consortium:
• British Heart Foundation• British Lung Foundation• Macmillan Cancer Support• Arthritis Research UK• King’s Fund• Health Foundation• Primary Care Rheumatology Society• Diabetes UK• RCGP
Public services face unprecedented challenges
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0% 20% 40% 60% 80% 100%
Depression
Schizophrenia/bipolar
Anxiety
Dementia
Asthma
Epilepsy
Cancer
Hypertension
COPD
Diabetes
Painful condition
Coronary heart disease
Atrial fibrillation
Stroke/TIA
Heart failure
Percentage of patients with each condition who have other conditionsThis condition only This condition + 1 other + 2 others + 3 or more others
The commonest long term condition is:
Multiple long term conditions
Care fragmentation is the norm and waste is endemic
The person who lives with LTCs is the ultimate delivery mechanism:
Day to day management is self management
The development of the Patient Activation Measure
Other constructs • Locus of control• Self efficacy• Readiness to change
Tend to be used as predictors of individual behaviours and do not capture the broad range of knowledge, skills, beliefs and behaviours needed to manage LTCs
Patient Activation Measure: 22 items
Development of the PAM. Hibbard J et al. Health Services Research 2004; 39(4): 1009-1032
Impact of shared decision making: some examples
• Surgery for benign prostatic hyperplasia in the United States and United Kingdom
• Hysterectomy for benign uterine conditions in the United Kingdom
• Surgery and percutaneous intervention for coronary disease in Canada
• Surgery for back pain in the United States
• Surgery for hip and knee pain in Canada
Shared Decision Making, Care Planning and the use of Patient Decision Aids
15
7% of population
14% of population
Shared Decision Making, Care Planning and the use of Patient Decision Aids
METHODS [3]
Intervention• Training of doctors and nurses (1-2 hours):• Principles of shared decision making• Importance and clinical effectiveness of decision aids• Evidence for treatment options in poorly controlled T2DM• Essential skills in risk communication
97
Shared Decision Making, Care Planning and the use of Patient Decision Aids