Breakout 3.2 Managing Multimorbidity in Practice - Dr Kevin Gruffydd-Jones
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Breakout 3.2 Managing Multimorbidity in Practice - Dr Kevin Gruffydd-Jones Box Surgery Wilts Member PCRS(UK) Respiratory Lead RCGP Member of NICE COPD Guidelines Committee and Asthma/COPD Clinical Standards Committees Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
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Breakout 3.2 Managing Multimorbidity in Practice - Dr Kevin Gruffydd-Jones
- 1. Managing Multimorbidity in Practice Dr.Kevin Gruffydd-Jones TAYSIDE CENTRE Box Surgery Wilts. BOX Member PCRS(UK) Respiratory Lead RCGP Member of NICE COPD Guidelines Committee and Asthma/COPD Clinical Standards Committees. Multimorbidity v co-morbidity • “Multi Morbidity” co-existence of 2 or more diseases in one person (Mercer et al Family Practice 2009.) • “Co-morbidity” Presence of other diseases in a person with a reference disease 1
- 2. Why bother? • 15.4 million people in England with at least one long –term condition( DoH 2012) • Estimated by 2025 increase of 42% • • 78% of all GP consultations • 70% Health and Social Care Budget, Why bother? • 60% patients in Scottish Study 2 or more conditions . More people under 65 than over 65 (Mercer BMJ 2012) • Canadian Study 69% 18-44, 93% 45-65, 98% > 65(Fortin et al 2007) • Associated with deprivation. Onset multimorbidity 10-15 years earlier in developing countries(Smith BMJ 2012) 2
- 3. Why bother? More Likely to : Die Early Be Admitted to Hospital Poor Quality of Life Multiple drugs Poor adherence Susan Smith BMJ 2012 http://www.pcrs-uk.org/resources/copd_guidelinebooklet_final.pdf 3
- 4. Patient-Centred Management of Stable COPD in Primary Care ALL PATIENTS Smoking cessation advice Exercise promotion Patient education/self management Pneumococcal vaccination Assess co-morbidity, Annual influenza vaccination ASSESS BMI: Dietary Advice >25 Specialist Dietary Referral if BMI <20 FUNCTIONAL SYMPTOMS? EXACERBATIONS? HYPOXIA? HOLISTIC LIMITATION ? CARE BREATHLESSNESS MRC score > 3 (Oral steroids/antibiotics/ Oxygen saturation Check social Hospital admissions) < 92% at rest in air) Support Short acting bronchodilators Optimise pharmacotherapy (e.g. carers and (see algorithm) FEV-1 < 30% (beta agonist/anticholinergic) benefits) for relief of symptoms. Predicted Optimise pharmacologic Treat co-morbidities. therapy Offer pulmonary Consider Palliative PERSISTENT SYMPTOMS rehabilitation therapy or secondary See pharmacotherapy Care referral for Algorithm Resistant symptoms Screen for Discuss action plans i PRODUCTIVE COUGH anxiety/depression including use of standby Consider mucolytics Refer to specialist oral steroids and antibiotics Refer for oxygen Palliative care teams assessment For end-of-life care. COPD is not just a disease of the lungs HEART FAILURE (20%) Cachexia/ Osteoporosis muscle wasting (11%-38%) 40% osteopenic in Depression “TORCH” (25%patients Metabolic syndrome FEV-1 <50%) (50% with 1 or more features) Lung function is poorly related to the impact of disease upon the patient(Paul Jones.PCRJ 2011). 4
- 5. Co-Morbidities in Practice Barnett et al Lancet 2012 Co-Morbidities in Practice Barnett et al Lancet 2012 5
- 6. Co-Morbidities in Practice COPD 3.5 co-morbidites (v 1.8) Sin et al ERJ 2006 Barnett et al Lancet 2012 Patient-Centred Management of Stable COPD in Primary Care All PATIENTS Smoking cessation advice Exercise promotion Patient education/self management Pneumococcal vaccination Assess co-morbidity Annual influenza vaccination ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20 HOLISTIC CARE Check social Support (e.g. carers and benefits) Treat co-morbidities. Consider Palliative therapy or secondary Care referral for 1. FEV-1<30% Resistant symptoms 2. Recurrent Hospital admissions 3. for acute COPD. Refer to specialist 4. Housebound Palliative care teams 5. BMI <20 For end-of-life care. 6. On LTOT Would you be surprised if this patient died within the next year? (6 months) 6
- 7. Patient-Centred Management of Stable COPD in Primary Care All PATIENTS Smoking cessation advice Exercise promotion Patient education/self management Pneumococcal vaccination Assess co-morbidity Annual influenza vaccination ASSESS BMI: Dietary Advice >25 , Specialist Dietary Referral if BMI <20 HOLISTIC CARE Check social Support (e.g. carers benefits) Treat co-morbidities. How does this fit in everyday management? 7
- 8. What evidence have we got so far? • NOT A LOT! Managing patients with multimorbidity: systematic review of interventions in primary care and community settings BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj. Susan M Smith, associate professor of general practice1, Hassan Soubhi, adjunct professor of family medicine2, Martin Fortin, professor of family medicine2, Catherine Hudon, associate professor of family medicine2, Tom O’Dowd, professor of general practice3 8
- 9. What evidence have we got so far? • 10 studies looking at interventions in primary care settings • 8 out of 10 studies US • ORGANISATIONAL(Multidisciplinary team, education , drug review(including pharmacist) SELF MANAGEMENT : education , structured self-mangement What evidence have we got so far? • Results mixed. • Some evidence of improvements in specific areas e.g medicines management • Results ? Better when specific co- morbidity looked at and when look at functional limitation. • Paucity of economic studies. 9
- 10. National Survey of Multi- morbidity in clinical practice with COPD as an examplar Dr Shoba Poduval Clinical Support Fellow and First5 GP Survey • 7 point questionnaire uploaded to survey monkey – What did you do? How did you do it? Why? What prompted you? – Overall impact -how this benefits patients, staff and the organisation – Lessons learnt, what went well? What didn’t work well? Advice for others 10
- 11. Survey • Open 29.11.12 - 8.2.13 • Thirty four responses • Thirteen reviewed- themes • Five case studies • Other Practices of note- telehealth Preliminary Results Themes • Outcomes • Motive • Evaluation • Patient selection & • Challenges invitation • Organisation • Staff • Housebound patients 11
- 12. Motives • QoF • PBC/CCG funding • Improving patient experience Patient selection & invitation • Disease registers • Disease severity stratification • Specific patient selection criteria 12
- 13. Staff • Practice team: GP’s, Nurses, HCA’s, admin staff • Community team: District Nurses, Community Nurses, Social Services, Pharmacists • Secondary Care Housebound • Visits by GP’s & Community Matrons • On-going support from Community Matron & Social Services 13
- 14. Outcomes • Patient and staff satisfaction • More appointment time available • Medication adherence • Reduced A&E attendance • Projected savings Challenges • Training • Organisation- time • Resources- templates • Funding 14
- 15. Discussion • What is your experience of managing multimorbidity? • Challenges? • Suggestions? So What do we do in Practice? Long term condition Clinics IHD/Diabetes/ Heart Failure etc. Chronic Care Model of Wagner (Proactive structured care, supportive self manage Care Planning 15
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- 17. CHALLENGES • Deciding on the co-morbidities • Content and Integration of Templates • Management of Housebound • Medicines Management Review • Stratifying Risk and use of Community Teams. 17