Long Term Conditions Risk Optimisation

Dr Junaid Bajwa

Conway Medical Centre, Greenwich

About me

• GP, CCG Governing Body Member NHS Greenwich (s)

• Associate in Public Health, NHS Greenwich (s)

• Council Member of the Clinical Senate, London

• NHS Fast Track Executive Programme

• GP Appraiser NHSE

• Programme Director, Greenwich VTS (s)

• Prepare to Lead alumni, NHS London

• Value Based Healthcare Alumni, Harvard Business School

The IHI healthcare Triple Aim

– 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

Multimorbidity: LTC

The working lunch…..

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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

• 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)• 16 face to face 10 minute appts• Referrals: 3 (pm)

“Exhausting”“Demoralising”

“I feel like a wrung-out rag at the end of

consultations”

“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”

GP’s and Nurses in deprived areas

struggle with LTC’s

Proactive management, not reactive

Long Term Conditions Module

Improving the experience of healthcare for

those with long term conditions

What if we used what we have?

Metrics

• HbA1c

• Cholesterol

• BP

• MRC

• eGFR*

• BMI

• Waist circ

• Audit C score

• PHQ9

• Being Housebound

• No of repeat

• Age >75

• Being a smoker

Long Term Conditions

• Cancer,

• COPD,

• Asthma,

• Diabetes,

• CKD 3,4,5,

• Hypertension,

• Rh Arthritis,

• AF,

• HF,

• Hypertension,

• Mental Health

condition,

• LD,

• Dementia,

• Parkinsons,

• Cirrhosis,

• being on the

GSF,

• Inflammatory

Bowel Disease,

• Stroke/TIA,

• Osteoporosis

What if we used what we have?

Metrics

• HbA1c

• Cholesterol

• BP

• MRC

• eGFR*

• BMI

• Waist circ

• Audit C score

• PHQ9

• Being Housebound

• No of repeat

• Being a smoker

Long Term Conditions

• Cancer,

• COPD,

• Asthma,

• Diabetes,

• CKD 3,4,5,

• Hypertension,

• Rh Arthritis,

• AF,

• HF,

• Hypertension,

• Mental Health

condition,

• LD,

• Dementia,

• Parkinsons,

• Cirrhosis,

• being on the

GSF,

• Inflammatory

Bowel Disease,

• Stroke/TIA,

• Osteoporosis

• Age >75

(Modifiable) (Fixed)

Within the metric….RAG

Metrics

• HbA1c

• Cholesterol

• BP

• MRC

• eGFR*

• BMI

• Waist circ

• Audit C score

• PHQ9

• Being Housebound

• No of repeat

• Age >75

• Being a smoker

RAG: R-2pts / A-1pt / G-0pt

• 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 3/yr 4/yr 5/yr

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

Thank you…

Find out More at the

MSD Healthcare Services stand