Commissioning Care Pathways for Chronic Diseases

James Gupta Medical Student | University of Leeds QIPP Lead | Windermere Medical Centre James.Gupta@hsthpct.nhs.uk

Overview & Aims

What are pathways, when do we use them and why do we need them? Developing a pathway-based approach to COPD commissioning How can we measure the impact of pathways on patient care? Commissioning for whole person care

Our experience (overview of the StHealth COPD project)

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

What is a Pathway?

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Post-op complications fell 33% Inpatient deaths by 40%

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

What is a Pathway?
Integrated Care Pathways (ICPs) provide a template for multi-disciplinary care that is evidence-based and co-ordinated. Clinical Governance, NHS Scotland 1

An integrated care pathway (ICP) is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. Oxford University Medicine 2
A care pathway is anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience. - Welsh National Leadership and Innovation Agency 3
1) NHS Scotland Clinical Governance, What are integrated care pathways, http://www.clinicalgovernance.scot.nhs.uk/section2/pathways.asp 2) Bandolier, Integrated care pathway, http://www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html 3) Welsh Assembly Government, Innovations in care 2003.

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

What is a Pathway?
A template for multidisciplinary care that is evidence-based and coordinated. Clinical Governance, NHS Scotland A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. Oxford University Medicine Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience. - Welsh National Leadership and Innovation Agency
James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Multidisciplinary

What is a Pathway?
A template for multi-disciplinary care that is evidence-based and coordinated. Clinical Governance, NHS Scotland A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. Oxford University Medicine Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience. - Welsh National Leadership and Innovation Agency
James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Multidisciplinary Evidence-based

What is a Pathway?
A template for multi-disciplinary care that is evidence-based and coordinated. Clinical Governance, NHS Scotland A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. Oxford University Medicine Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience. - Welsh National Leadership and Innovation Agency
James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Multidisciplinary Evidence-based Anticipated

What is a Pathway?
A template for multi-disciplinary care that is evidence-based and coordinated. Clinical Governance, NHS Scotland A multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. Oxford University Medicine Anticipated care placed in an appropriate time frame, written and agreed by a multidisciplinary team. It has locally agreed standards based on evidence where available to help a patient with a specific condition or diagnosis move progressively through the clinical experience. - Welsh National Leadership and Innovation Agency
James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Multidisciplinary Evidence-based Anticipated

Local & Specific

Available from sthealth.org.uk/copd_resources.htm

Why do we need pathways?

Time & budget restraints Patients receiving care from different professionals

Need to make care as efficient as possible and reduce variation

Every patient is unique, but key features will be seen repeatedly

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

When do we use pathways?

We all use pathways, every day Structured decision-making process based on knowledge (evidence) and experience

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

What are the benefits of using pathways?

1)

Patients receive care that is not only more consistent, but also of a higher standard and more up to date with the latest evidence Clinicians feel more confident and can get more done in less time Resources are used more appropriately Emergency / non-elective admissions can be reduced Rotter et al Cochrane Review 2010

Rotter et al, Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006632. DOI: 10.1002/14651858.CD006632.pub2. 2) Campbell H, Hotchkiss R, Bradshaw N, Porteous M, Integrated care pathways. BMJ 1998, 316(7125):133-7. 3) Lowe C, Care pathways: have they a place in the new National Health Service? J Nurs Manag 1998, 6(5):303-6.

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Developing a Pathway Approach to COPD Commissioning

Multidisciplinary Chest physicians GPs Practice nurses COPD / community nurses Practice managers Pharmacists Respiratory physiotherapists Smoking cessation advisers Spirometry technicians Committed Lead: clinical and managerial experience

1
2

Assemble a team
Design a pathway

Implement it

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Developing a Pathway Approach to COPD Commissioning

Assess your current patient journey:

Time wasters Black holes Bottlenecks

1
2

Assemble a team
Design a pathway

Plan a new patient journey

THINK OUTSIDE THE BOX!

Listen to the views of ALL your MDT equally regardless of seniority or qualifications. Expect some culture shock between primary and secondary care professionals, encourage it!

Implement it

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Primary/Secondary Care Conflict

Peter Consultant chest physician

Wendy Practice nurse

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Primary/Secondary Care Conflict

Patients should have full post-bronchodilator spirometry performed by an accredited technician every time they come for a review other measures of lung function simply arent accurate enough Were really busy in primary care so dont always have time to do spirometry often we can see how a patient is getting on by asking them questions, their general appearance, peak flow etc

Peter chest physician

Liz Pathway lead

Wendy Practice nurse

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Developing a Pathway Approach to COPD Commissioning

The hardest part Simply distributing the final pathway will not work Has to be done alongside structured clinician education

1
2

Assemble a team
Design a pathway

Advertise the mutual benefit:

Improve patient care AND Make your job easier!

Resistance to change

Implement it

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Measuring the impact of pathways on patient care

QOF
Admissions / Bed Days

Flu jab L12M FEV1 L15M MRC score L15M

NICE

Exacerbations

Inhaler Technique

PHQ

Respiratory Prescribing

Not acceptable!!
Many ways to measure REAL changes in the patient experience
Pulmonary Rehabilitation Referrals Quit Rates

Identify them early!

Clinician Confidence

Patient Satisfaction

FEV1 at Diagnosis

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Commissioning Quality Markers: Measuring the impact of pathways on patient care

Must ultimately focus on REAL clinical outcomes

May take many years to see full benefit of these Surrogate endpoints in meantime Cost reductions / QIPP
Data recording Early detection Bed Days / Admissions Mortality QOL Cost Reduction

Primary Endpoints

FEV1 Decline Medication Adherence Smoking Quit Rates NICE Compliance

Surrogate Endpoints

Process Markers

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Commissioning Quality Markers

Should focus on real outcomes where possible

Admissions / Exacerbations Quality of life (King George, PHQ9) Smoking quit rates Costs

Referrals Prescribing

% referred for pulmonary rehab

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Commissioning for Whole-Person Care

COPD is being increasingly seen as a systemic disease with associated co-morbidities: Depression Heart Failure Osteoporosis (corticosteroid-induced) Hypertension Cardiovascular disease Lung cancer Bronchiectasis Yet current care-pathways do not operate like this definitely something to bear in mind Good model: diabetes common co-morbidities / complications are treated and screened for under one (relatively) cohesive model

1) Barnes PJ, Celli Br, Systemic manifestations and comorbidities of COPD. Eur Respir J 2009, 33(5);1165-85

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Case Study: StHealth COPD Project

Joint working initiative with GlaxoSmithKline (DH toolkit) StHealth Practice Based Commissioning Consortium (now Shadow CCG)

Focused on enhanced management AND early detection of COPD

Pathway-based Led to reduction in hospital admissions and prescribing costs, increase in patient satisfaction, quality of reviews,

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Key Pillars

Stakeholder Engagement

Outcome Measurement

Pathway Development

Screening

Clinician Training

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

1. JW business case committing 290k

2. Patient pathway and treatment protocol developed

3. Developed and implemented a training and mentoring programme

6. Measure patient experience of service

5. Investing in Vitalograph COPD6 FEV1 monitors

4. Implemented POINTS audit software

James Gupta 2012 | UK/MARK/0023/10 April 2010 james.gupta@hsthpct.nhs.uk

QIPP

James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Summary

Pathways are multidisciplinary, evidence-based, local & specific Take best available evidence and adapt it to local needs & provision Can increase standard of care for chronic conditions Reduce costs, admissions/bed days and improve quality of life Need to identify commissioning quality markers

James Gupta 2012 | james.gupta@hsthpct.nhs.uk