Facing the Care ChallengePractice

A pathway approach to implementing NICE guidance

A nurse led model

Susan Oliver MSc FRCNNurse Consultant Rheumatology

Independent

Stepping into new territorya 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, co-

morbidities– Need to manage disease control

Oliver & Bosworth (2010) The user patient journey. In Rheumatology Evidence based practice for physiotherapists and occupational therapists. Elsevier.

Nursing modelTeam approach

Improve symptom relief & enhance self

management

Work to improve functional ability & promote

independence

Provide Education, enhance concordance and reduce risk

Point of access for team support

Increasing role in assessment, monitoring & screening for treatments

Supporting social & psychological

adjustment to disease

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 capacityThe 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 carePathways

• 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 careTransparency

Equity of access

The FoundationsPatient Experience

The Healthcare practitioner’s perspective

Patient Stories v standards and guidelines

• Evidence Based Care

• Standards

• Guidelines

First stepsReferral 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 principlesImplementation

• 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 cycleSystematic and equitable?

Clarity of pathway and management?

Triage, rapid access and effective use of the phone for all? Outcomes?

Patient experience?Time to access rapid advice?

Equity of access to MDT support? Value of approach and strategies? Annual review?

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 on-

going 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

ConclusionNurse 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