Identificación de factores claves en la gestión de casos para pacientes crónicos en situación de complejidad Claire Goodman Professor of Health Care

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2 Identificación de factores claves en la gestión de casos para pacientes crónicos en situación de complejidad Claire Goodman Professor of Health Care Research Centre for Research in Primary and Community Care

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4 Presentation Background Initiatives to support integration of services for people with complex needs Key attributes of services The way forward?

5 Multi morbidity by age Barnett et al. Lancet 2012

6 Income reducing Wife seems more forgetful Anxious about future Payments due Debt Daughter back at home 2 grand daughters Alcohol and drug problems Nurse concerned about non compliance Change diet : less fat, sugar,carbs More Exercise Organise visits and transport Endocrinologist Diabetic Dietician Check his Pain feet Bad back Hypertension Dizzy Can t sleep Neuropathy Depression High Obese Cholesterol Take Pills Podiatrist Adapted from Victor Montori Mayo Clinic : Minimally Disruptive Medicine

7 Cumulative Complexity Clinical and social factors accumulate over time Interact to shape health service use, selfcare, and health Need to reduce the impact of treatment burden Need for patient centred approaches reconsider disease centred approaches Shippee, N.D., Shah, N.D., May, C.R., Mair, F.S. & Montori, V.M. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. Journal of Clinical Epidemiology, 2012

8 Organisation of NHS commissioning April 2013

9 The English experience People with long term conditions = 70% of the total health and social care spend in England 40% increase in emergency admission maybe due to increase of oldest old with complex needs

10 Policy response Health promotion, self care Early identification, treatment and management Integrated care(vertical) Co-ordination of care Care pathways Targeted interventions to avoid crises or support recovery and rehabilitation

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12 Evidence is mixed Continuity of care with a family physician Hospital at home instead of admission Self management Generic or disease specific case management Comprehensive Geriatric Telemedicine Integrated Care Pilots Pay for performance Structured discharge planning Pharmacist led medication review Partnerships for Older People Pilots Virtual wards

13 Context Recurring themes Not introduced as planned Short term evaluations Evidence of reduced cost from improved care not demonstrated Cost of intervention often not assessed

14 IMPACTABILITY Lewis 2012 Discriminate between those patients that would want and benefit from the services and those that did not

15 Do different models of working have a different impact over time? What was the experience of different models of care from a patient perspective? Are certain attributes or mechanisms more significant than others? Is frailty a useful clinical measure? Goodman, Drennan et al 2012 Topic: A study of the effectiveness of inter professional working for community dwelling older people (TOPIC) NIHR

16 Review of process of care and its effectiveness How different components and processes of interprofessional working for older people living at home with complex needs had an impact on outcomes Identify the models of working that provide the strongest evidence base for practice with community dwelling older people Trivedi, D., Goodman, C., Gage, H., et al (2013), The effectiveness of interprofessional working for older people living in the community: a systematic review. Health & Social Care in the Community, 21: doi: /j x

17 What model of IPW is effective from the patient Integrated team model perspective? Collaborative model Case management model

18 TOPIC PHASE TWO Prospective case studies in 6 different sites looking from the patient perspective 3 different models of inter professionals working Tracking the care older people and their carers receive over nine months

19 Figure x Visio 51A4

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22 Key attributes for older people with complex, multiple and Continuity Information Relational Management ongoing needs Co-production Horizontal integration Identified key/care worker

23 Specialist care GP District nurse carer Social worker charitable provider /community Horizontal (matrix )integration from the older person s

24 Understanding frailty Fluctuating disability day-to-day instability, resulting in patients with good,independent days, and bad days on which (professional) care is often needed. Clegg,Young, Iliffe et al 2013 Lancet

25 Assessment of Frailty Cuts across unidisciplinary definitions of effectiveness. Potential identification of those requiring integrated care, Planning care packages, Monitoring the health status Poltawski, L., Goodman,C., Iliffe, s. et al 2011 Frailty scales: their potential in interprofessional working with older people : a discussion paper Journal of Interprofessional Care :4,

26 Conclusions To achieve integrated working for older people with complex needs consider if the services systems of care fosters: Relationship styles of working that enable co- production, continuity and review over time Horizontal integration over time The identification of a case manager (often a nurse) for others to work and liaise with Review of impact of different services on

27 The benchmark for any model of care designed for patients with complex needs and multi morbidities is the extent to which the patient ( and their carer) is integrated into the organisational model rather than being seen as an external beneficiary of it.

28 Disclaimer HS&DR Funding Acknowledgement: This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number ). Department of Health Disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the

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