Long Term Conditions Risk Stratification Dr Junaid Bajwa Conway Medical Centre, Greenwich

About me GP Principal, Greenwich RCGP Clinical Commissioning Champion Associate in Public Health, NHS Greenwich Medicine’s Management Lead NHS Greenwich GP Appraiser NHS SEL Chair Greenwich LMC Education Lead GPCC Prepare to Lead alumni, NHS London 2

Multimorbidity: LTC The majority of >65s have 2+conditions, & the majority of >75s have 3+ conditions More people have 2 or more conditions than only have 1

Most people with any long term condition have multiple conditions in Scotland

The working lunch….. 16 face to face 10 minute appts Monday Tues Weds Thurs Fri 0800am   0810am 0820am 0830am 0840am 0850am 0900am 0910am 0920am 0930am 0940am 0950am 1000am 1010am 1020am 1030am 1040am 1050am 1100am 1110am 1120am 1130am 1140am 1150am 1200pm 1210pm 1220pm 1230pm 1600pm 1610pm 1620pm 1630pm 1640pm 1650pm 1700pm 1710pm 1720pm 1730pm 1740pm 1750pm 1800pm 1810pm 1820pm 1830pm 1840pm 1850pm 1900pm 16 face to face 10 minute appts Telephone encounters: 5-10 Home visits (2-3) Referrals: 3 (am) Review blood tests/Investigations Post/ Fax/ Email (75-100 letters per day) Referrals: 3 (pm) What about: QoF/ LES/DES/ CIS/ Additional Services/ Child Protection/ GSF/ Information Governance/ CQC/ PRG/ Practice Meetings/ KPI’s/ Audit: Research/ Reviewing Prescribing/ HR issues/ LMC/ Public Health/ CCG ….(+++++++++++)…. Stepping outside the chaos to manage LTC holistically Proactive, not reactive medicine 5

GP’s and Nurses in deprived areas struggle with LTC’s “Demoralising” “Exhausting” “If you’re too caring ... you’ll crack up in a place like this. Our boundaries lie where they are because they have to at the moment” “I feel like a wrung-out rag at the end of consultations”

"Commodities are fungible, goods tangible, services intangible, and experiences are memorable." (Lee) Proactive management, not reactive  Self Management systematic transfer of some knowledge and power to maximise self-management and choice, where the GP acts as a navigator. Motivating Staff and Patients Focus on compassion, autonomy, mastery and purpose (correspondence (personalized, targets individualized), pt experience, face/face, telephone) How can we do the right thing, but also make the lives of those around us easier at the same time

Opportunities & challenges? ‘A pessimist sees the difficulty in every opportunity, … an optimist sees the opportunity in every difficulty’ Sir Winston Churchill

Long Term Conditions Module Improving the experience of healthcare for those with long term conditions

Risk Stratification The dilemma of "defining risk" for our patients on long-term conditions Is it just the number of registers? What about outside Qof: parkinsons, cirrhosis, inflammatory bowel disease….children…. Existing: Hospital Admission Risk programme (HARP) High–impact User Manager (HUM) Patient At Risk of Re-hospitalisation (PARR) Probability of repeat admissions (Pra) tool http://www.yourdiseaserisk.wustl.edu/ Looks at: Cancer/Diabetes/Heart Disease/Osteoporosis/Stroke http://www.readmissionscore.org/ Heart Attack/ Heart Failure/ Pneumonia

What if we used what we have? Metrics Long Term Conditions HbA1c Cholesterol BP MRC eGFR* BMI Waist circ Audit C score PHQ9 Being Housebound No of repeat Age >75 Being a smoker Cancer, Dementia, COPD, Parkinsons, Asthma, Cirrhosis, Diabetes, being on the GSF, CKD 3,4,5, Hypertension, Inflammatory Bowel Disease, Rh Arthritis, Stroke/TIA, AF, Osteoporosis HF, Mental Health condition, LD,

What if we used what we have? Metrics Long Term Conditions HbA1c Cholesterol BP MRC eGFR* BMI Waist circ Audit C score PHQ9 Being Housebound No of repeat Being a smoker Cancer, Dementia, COPD, Parkinsons, Asthma, Cirrhosis, Diabetes, being on the GSF, CKD 3,4,5, Hypertension, Inflammatory Bowel Disease, Rh Arthritis, Stroke/TIA, AF, Osteoporosis HF, Age >75 Mental Health condition, LD, (Modifiable) (Fixed)

Within the metric….RAG Metrics RAG: R-2pts / A-1pt / G-0pt HbA1c Cholesterol BP MRC eGFR* BMI Waist circ Audit C score PHQ9 Being Housebound No of repeat Age >75 Being a smoker G (6.5-7.5), A (7.5-8.5); R (>8.5) > 4:2: A: 1 pt if above this ratio (>150/90; if DM/CKD/CHD >140/90) 1 pt if above G: 3,A: 4, R: 5 G (CKD2 60-89); A (CKD3 30-59); R (CKD4,5 ie < 29) A: (Obese**) R (:morbid obesity) A: 1 pt if above norm R: (>5) (last recorded within 3m) R: 15-27; A: 5-14 A: 1 point Repeat medications (>5): A 1 pt if above A 1 pt if above 75 A 1pts

Managing the chaos: Proactive vs Reactive Cumulative totals within each of the categories would then allow a 360° review of your registered population Could you then establish a set of rules re: appointments; removing the monthly letters for each review/ reduce waste in the system; offer extended appointments with a focus on self management- improving the patient experience Green Amber Red Dr appts (?around bday) 2/yr 3/yr 4/yr Nurse appts 5/yr

MSDi LTC Module The software will allocate a R,A,G, status to patients based on: The number of long term conditions they have Indicators used to define whether those conditions are optimally managed No of visits a patient has made to the surgery over the last 12 m Flexible: to allow for user defined thresholds and weightings to be allocated to each of the above parameters A care plan will be generated for the patient which will include the number of appointments that a patient will have over the following 12 m which are dedicated to the optimal management of that patients conditions. The software is practice based At locality level anonymised data can be aggregated and accessed through a web-based portal, allowing risk to be stratified across a geography.

Set-up Rag Rating Criteria

Patient Stratification by No. LTCs

Patients with RAG rating reasons

No. Patient Interactions with in last 12 months

% Patients with No. Diseases by Age

Patients not controlled

PDSA: future add ons PDSA cycle Coding: Number of hospital admissions A(2); R(>3); Quantify length of stay in hospital QRISK®2 calculates your risk of cardiovascular disease(R >30%) (A>20) QDScore® algorithm calculates your risk of Type 2 diabetes.) QoL score (would be useful to include this metric- we do not currently assess this in primary care) Looking at social determinants of health: e.g. personal/ household income, social housing, postcode, use of carers, social isolation “Not all that can be counted, counts. And not all that counts can be counted.” -- Albert Einstein

Personal Health Plan

Personal Health Plan

Personal Health Plan

Improving the Patient Experience SDI. 12.GB.107042.SL Date of Preparation: May 2012

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