Facing the Care Challenge
Practice
A pathway approach to implementing NICE guidance
A nurse led model
Susan Oliver MSc FRCN
Nurse Consultant Rheumatology
Independent
Stepping into new territory
a nurse led inflammatory arthritis model
Exploring nursing leadership driving
improvements in clinical care
Overview
• Example of good practice - rheumatology
service development
• Commissioned service in Oldham
– Collaboration between specialist and community
services
– Transfer of patients to a community based model
• Patient experience and needs
• Framework, guidelines and workforce
Rheumatology
• Discuss the Rheumatoid Arthritis Example (RA)
• Rheumatological conditions e.g.
– Inflammatory forms of arthritis, systemic lupus,
scleroderma
• Inflammatory joint diseases (3%)
– Rheumatoid Arthritis, Psoriatic Arthritis
– Expensive treatments, quality of life impact, comorbidities
– Need to manage disease control
Oliver & Bosworth (2010) The user patient journey. In Rheumatology Evidence based practice for physiotherapists and
occupational therapists. Elsevier.
Nursing model
Team approach
Improve symptom
relief & enhance self
management
Point of access for team
support
Supporting social &
psychological
adjustment to disease
Provide Education, enhance
concordance and reduce risk
Increasing role in
assessment, monitoring
& screening for
treatments
Work to improve functional
ability & promote
independence
Rheumatology Nursing
• Clinical Nurse Specialists
– Studies have demonstrated safety and efficacy
equivalent to a junior doctor with ↑ patient
knowledge1
– Manage triage and early arthritis clinics2
– Cost effective & valued by patients in provision of
telephone advice line support 3, 4
– Drug monitoring and well being 5
– 28% are nurse prescribers6
1. Hill (2003) 2. Gormley et al, (2003) 3. Hughes et al (2002) 4. National
Audit Office Report (2010), 5. Ryan (2006) and 6. RCN (2009)
Change the way we manage capacity
The essence of nursing role in rheumatology but...drivers
must
• Understand the demand
– Measure it
– Plan capacity to account for variation in demand
– Plan for no waiting list or queue = no delay for nursing care/team approach
• Reduce the number of steps in the process
– remove non-value adding activities
• Reduce the variation in capacity
– Reduce the number of queues at each step
– Match different team members pathway input
• Improve bottleneck productivity = throughput
Rationale for evidence based care
Pathways
• More...real change in the pipeline1
– Commissioners/Consortia lack of
knowledge/time/interest
– Regional variances in pathways of care
– Need to optimise efficiency and highlight quality2
• Matching capacity with demand
• Structured and rigorous focus on;
– Activity (N/FU ratio)
– Costs and outcomes
• Quality indicators and PROMs
– Use of Evidence based care/guidelines
1. Lord Darzi High Quality Care for all (2008) 2. Equity and Excellence, Liberating the talent of the NHS ,(2010).
Why pathways - patient
• Transparency of pathway
• Ability to plan and consider future issues
• Aids documentation and recall of their patient
journey
• Key points in pathway linked to assessment
and outcomes
• Quality of Life an important and valued
indicator1
• References: Lord Darzi Review High Quality Care for All (2008)
Why pathways – clinical
• Greater use of teams expertise
• Potential to reduce variances in care
– Document clearly exceptions to routine path
• Identification of true versus perceived
bottlenecks and long waits
• Less ‘faces’ but more effective interactions
• Bridges gaps between provision
– Primary/secondary
– NHS/Voluntary sector
Why pathways - financial
• Provider can predict more clearly activity and
resources required
• All team members providing care are incorporated &
costed
– Implications regarding cheapest competent practitioner
• Costs can be more accurately predicted/plotted
against patient flows
• Commissioners can identify
– Activity + Costs + Outcomes
– Variances can help future contracting/financial changes
• Managing capacity and demand
Healthcare delivery 2010
and on.....
The future in healthcare delivery
• Deliver improved services with same amount
(or reduced levels) of income
• More for less + demonstrate strong evidence
of quality and value of steps in service
delivered
• Identify the patient experience and outcomes
Optimising patient care
Transparency
Equity of access
The Foundations
Patient Experience
The Healthcare practitioner’s perspective
Patient Stories v standards and guidelines
• Evidence Based Care
• Standards
• Guidelines
First steps
Referral pathway
Patient
• Positive messages
• Musculoskeletal information
• Worthwhile seeking clinical opinion
• Knowledge of musculoskeletal conditions
• Access to succinct and evidence based referral criteria
Primary Care according to local service
Team
Specialist
Team
• Referral criteria that apply to service and accessible
• Support and good communication options for Primary
Care Teams
• Service re-design to ensure effective pathway
The King’s Fund Report (2009) The patient and healthcare professionals perceptions of
Rheumatoid Arthritis Care. London
Putting evidence into practice
The Nursing Model
• Biopsychosocial model of care
• Optimal management achieved with a holistic and
patient centred approach1
–
–
–
–
–
Agreed goals
Negotiated treatment plans2
Informed decision making2
Self management & patient preferences2
Transparent framework of support
1. Richards & Coulter Is the NHS becoming more patient-centred? Picker Institute. London. (2007)
2 Coulter A and Ellins (2007) Effectiveness of strategies for informing, educating and involving patients. BMJ. 335. 24-27
Pennine MSK model for RA
• Based upon NICE RA management guidelines (2009)
• Diagnosis by Consultant Rheumatologist
• Referral to nurse led clinics
• Intensive management 6 weekly assessment + telephone consultation +
rapid access service
• Management based on disease control
• Red Flags to guide referrals back to medics
• Protocol driven treatment plan
• Data collection using the EMIS system
• Patient held record
• Disease control
• Reduce follow up care when stabilised to annual review with access to
telephone review+ rapid access service
• Review by MDT according to need.
Information on Pennine MSK http://www.pmskp.org/index.html
Framework
• Patient pathway
– All steps in pathway outlined
– Each drug outlined with risks and benefits +
monitoring
– Exceptions and red flags etc – referred back to
physician
• Patient Group Directions (PGD) and policies
– Symptom and disease control
• All clinicians actively involved with pathway
• A staged and integrated approach to transfer of
patients from specialist to community services
NICE RA management principles
Implementation
•
•
•
•
Required re-design of services with investment
Patient required early and prompt review until disease control
Heavy front loaded activity required service re-design
Frameworks for nursing practice
– Development of nursing competencies
• Plan for enhancing nurse specialist expertise
• Independent nurse prescribers, joint injection
– Policies and patient group directions
• Structured patient pathway essential
– Capacity and demand
– Competencies at each stage of pathway
– Clarity re patient on or off pathway and when to seek
medical advice
The Nursing issues – started with
• Overall accountability Nurse Consultant (Partner)
• One PT Nurse Consultant
• (Independent – contracted service)
• 1 Part Time(PT) Nurse Specialist in rheumatology (band
8)
• 2 PT nurses working in service who required additional
training (band 6)
– Osteoporosis and practice nurse /community nurse
expertise
• 2-3 Healthcare workers – chiefly deployed in
orthopaedic, triage and pain services
• Good administrative support and management
Patient clinical assessment cycle
Equity of access to MDT support?
Value of approach and strategies?
Annual review?
Systematic and
equitable?
Annual Multiprofessional team
support
Disease
Assessment
Access to rapid
symptom control
Disease Assessment >3.2
Dose escalation/Treatment
change
Flare
management
Clarity of pathway
and management?
Disease
Assessment
<3.2
Rapid access
Telephone
Support
Patient
experience?
Time to access
rapid advice?
Triage, rapid access and
effective use of the phone for
all? Outcomes?
Innovation example
Patient benefits & Cost effective
Background: Specialist services cost - day care activity
patients attending for intramuscular methotrexate
(once a week) 30 patients tariff (£655 pp)day case
tariff.
Innovation:
Community education day all patient invited
– Education on conversion from IM to Subcutaneous
methotrexate.
– Group sessions of 6 with nurse to teach SC administration
– Presentations by team and supplier of new treatment
option (delivered to patients home)
– PCT made significant cost savings/patients care improved
On-going transfers
• Status > 800 <2000 patients transferred from
specialist services to community services
• Chiefly managed by nurses following diagnosis
• Treating to target according to NICE principles
• Tracking on or off pathway
• Patient involvement
• Customer Excellence Award (2009)
Demonstrating the value of new
models
• Historical challenges in demonstrating the unique value of the nurse
specialist in improving patient care (Oliver and Leary 2010).
• Computer system – templates and data systems
– Proposed new electronic system being considered incompatible with
previous system
• Continuous education training/updates to team to maintain pathway
approach
– Breaking old habits sustaining new ones
• New policy changes/resource/funding
• Training of nursing team
– New substantive part time senior rheumatology lead nurse (PT)
• Undertaking joint injection course
– 1 Nurse undertaking Prescribing course & 1 on waiting list for NPC
– 1 nurse attending rheumatology masters & 1 BSC course on chronic
disease nursing
Oliver and Leary (2010) Musculoskeletal Care, [8] 3, 175-177
Opportunities
• Nursing workforce
– Various expertise provided additional patient benefits
• Competencies in;
•
•
•
•
cardiovascular disease and assessment
osteoporosis management
Orthopaedic referral and assessment
Newly appointed nurse – linked to academic unit to support ongoing training and development
• Enhanced participation and standards of care
with all multi-disciplinary team
• Patient input vital to service development
Issues
• Evidence based practice balanced with health
policy drivers/costs
• Disease specific evidence versus generic evidence
– Still limited research in specific disease areas
undertaking new models of care
• Targets and quality indicators
– Data capture of benefits traditionally focus on target
driven areas
– 80% of referrals seen with 3 weeks.
– Patient Satisfaction Surveys regularly undertaken
– (see website) http://www.pmskp.org/index.html
Evaluation
• Frequent reviews of service and team working to:
– Review deviance from pathways and planning needs
– Develop robust quality indicators
• Include tools for ethnic and minority needs
– Improve patient involvement
• Consider patient population
– Review governance and competencies
– Demonstrate cost effectiveness
• New frameworks/commissioners
• Data collection should show benefits re steps of pathway
– quality indicators, patient experience and cost effectiveness
(QUIPPs).
– Consider the impact of high quality administrative support to
nurse activity
Conclusion
Nurse Led Models
• Evidence in the provision of specialist disease
specific nursing interventions remain scanty
• Nurse Prescribers benefit patient journeys in
managing risk and advising GPs
• Protocols/policy/PGDs labour intensive but
essential
• Patient outcomes and cost effectiveness are
not mutually exclusive.
Discussions