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Modernising Rheumatology Services

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Modernising Rheumatology Services Powered By Docstoc
					 Integrated and Partnership
Working with the Acute Sector
               Dr Richard J Reece
            Consultant Rheumatologist

                Rheumatology Department
    Calderdale and Huddersfield NHS Foundation Trust
    Rheumatology – an Exciting
           Specialty?
• In the last decade
  – New immunosuppressants (DMARDs)
     • Leflunomide, mycophenolate
     • Combination therapies
  – Biologics
     • Infliximab, Adalimumab, Rituximab
     • Etanercept, Abatacept
  – Improved Imaging
     • MRI, USS
  – Better knowledge of disease pathogenesis
Rheumatology in CHFT is a Success!
• Established Inter-disciplinary Team
    – 2 Consultants
    – 2 Junior Doctors
    – 2 Clinical Specialist Physiotherapist
    – 5 Clinical Specialist Nurses
•   Effective Working Practices
•   Delivering Evidence Based Care
•   Implementing NICE Guidance
•   Active Research Programme
                  Performance
•   Short waiting times (new to f/u ratio 1:2.8)
•   Low levels of complaints
•   Service valued by patients / carers
•   Good relationships with PCT colleagues
•   Shared Care Protocols in place
•   £4.0m annual spend for biologics, day case and
    in-patient services in Tertiary Care
    > 50% on biological treatments!
               Clinical Challenge
• Small team    vs large     clinical workload
    –   3600   Rheumatoid arthritis patients
    –   400    Psoriatic arthritis patients
    –   200    Ankylosing spondylitis patients
    –   300    Connective tissue disease patients
•   Condition Specific Clinics
•   Annual reviews of chronic disease patients
•   Telephone Advice Line Service
•   Aggressive Discharge Policy
   The Patients’ Perspective



How does our service look to you?
     Darren Hawkins

A Patient’s Perspective
         Relationship



Clinic              Patient
   Relationship




Clinic            Patient
         Relationship




Clinic                  Patient
         …occasional




Clinic          x      Patient
         …alone




Clinic            Patient
         …language




Clinic               Patient
         …the system




Clinic                 Patient
Could a clinical web site help?
Access

            Patient




Clinician
    Sharing

                        Patient




       Clinician

Clinician
            Clinician
  Clinician
                         Access

                       Patient
                                            Patient

      Patient



                           Clinician
                                                      Patient
Patient             Clinician
                                Clinician
                      Clinician



                                                 Patient
          Patient


                         Patient
                    Discussion

                       Patient
                                            Patient

      Patient

                       “Has
                     anybody
                     been..?”
                            Clinician
                                                      Patient
Patient             Clinician
                                Clinician
                      Clinician



                                                 Patient
          Patient


                         Patient
                    Appointments

                        Patient
                                             Patient

      Patient



                            Clinician
             ?                                         Patient
Patient              Clinician
                                 Clinician
                       Clinician



                                                  Patient
          Patient


                          Patient
                     Efficiency

                       Patient
                                            Patient

      Patient



                           Clinician
                                                      Patient
Patient             Clinician
                                Clinician
                      Clinician



                                                 Patient
          Patient


                         Patient
                             Information

                                 Patient
                                                          Patient

      Patient
                             Updates



                                                   Info
                                       Clinician
                                                                    Patient
Patient                      Clinician
                Activities               Clinician
                    A...
                    B…          Clinician
                    C…
                    D…




                                                               Patient
          Patient


                                   Patient
                           Participation

                                 Patient
                                                          Patient

      Patient
                             Updates



                                                   Info
                                       Clinician
                                                                    Patient
Patient                      Clinician
                Activities               Clinician
                    A...
                    B…          Clinician
                    C…
                    D…




                                                               Patient
          Patient


                                   Patient
                              Feedback
                                                          Me



                                 Patient
                                                               Patient

      Patient
                             Updates



                                                   Info
                                       Clinician
                                                                         Patient
Patient                      Clinician
                Activities               Clinician
                    A...
                    B…          Clinician
                    C…
                    D…




                                                                    Patient
          Patient


                                   Patient
                                GPs too!
                                                          Me
     GP

                                 Patient
                                                               Patient

      Patient
                             Updates



                                                   Info
                                       Clinician
                                                                         Patient
Patient                      Clinician
                Activities               Clinician
                    A...
                    B…          Clinician
                    C…
                    D…




                                                                    Patient
          Patient


                                   Patient
                              Complex?
                                                      Me
     GP

                                 Patient
                                                           Patient

      Patient
                             Updates
                                “Has
                              anybody
                              been..?”             Info
                                       Clinician
                                                                     Patient
Patient                      Clinician
                Activities               Clinician
                    A...
                    B…          Clinician
                    C…
                    D…




                                                                Patient
          Patient


                                   Patient
             No. Self-Service!
                                                      Me
     GP

                                 Patient
                                                           Patient

      Patient
                             Updates
                                “Has
                              anybody
                              been..?”             Info
                                       Clinician
                                                                     Patient
Patient                      Clinician
                Activities               Clinician
                    A...
                    B…          Clinician
                    C…
                    D…




                                                                Patient
          Patient


                                   Patient
 Integrated and Partnership
Working with the Acute Sector
        continued . . .
              Dr Richard J Reece
           Consultant Rheumatologist

               Rheumatology Department
   Calderdale and Huddersfield NHS Foundation Trust
        The Dark Truth is……
• Condition Focussed Clinics
  – Busy, “Silo” working, ?meet patient aspirations
• Delivering Consistent Care
  – <10% new RA patients referred to Therapy Services
• Patient Self-Management Programme
  – Non-existent
• Shared Care with Primary Care
  – Inconsistent
• Communication difficulties with PCTs and
  Tertiary Care
As a Clinical Team we asked
         Ourselves?
  Is Service Redesign Necessary?
                Yes!

  Is Service Redesign Avoidable?
Not if we want to provide a Specialist
     Service that Primary Care will
             Commission.
We want to empower
our patients who
have long-term
arthritis conditions,
to involve them in
planning their care, to
help them with self-
care and to provide
better access to
information and
support.
       Strategic Partnerships
• Designation as UK Pilot Site for
  Rheumatology Service Transformation by
  Long Term Conditions Team, DH
• ISIP - Local Health Community
  Demonstrator Centre Status for RA
  service Redesign (16 across NHS)
• Health Foundation “Co-creating Health”
  Initiative – 1 of 8 sites across UK to
  develop a new model of self-management
  for Musculoskeletal Pain
        Strategic Objectives
• Baseline Data Assimilation
• Mapping of Patient Journeys and Workflow
• Service Satisfaction Surveys
• Develop suite of “Care Models” and
  Integrated Care Pathways (ICPs)
• Securing Patient, Commissioner and
  Provider approvals
• Implement, support, evaluate and sustain
  transformed service
                  Outputs
• Comprehensive annual inter-disciplinary
  clinical assessments of all patients in
  community based setting
• Patients and PCT colleagues integral to
  the care planning process
• Offer patient choice of transferring Biologic
  therapies / Day Cases to CHFT
• Educational and Self-Care Support
  Strategy for RA patients and Carers
                     Benefits
•   Reduced PCT & hospital attendances
•   Reduced direct / indirect costs
•   Delivering on DH targets
•   Improved Governance
•   Streamlined communication
•   Improved patient self-care
•   Option of repatriation provided for appropriate
    day case / high cost drug patients currently
    being treated in Tertiary Care
    1. Huddersfield & Calderdale Rheumatoid Arthritis Benefits Dependency Network v3.0

   Enablers          Work Streams              Outcomes                Benefits              Priority
                     (& Actions to Change)                                                  Objectives
                                             1. An agreed model
                                             of care for RA &        1. Reduced
                                             improved evidence       variation in how RA
1. NSF’S/OHOC..      1. Model of                                     managed across         1. Appropriate
                                             based pathways                                 use of LTC
                     Care/Integrated                                 LHC
                     Care Pathway                                                           healthcare
                     Development             2. Comprehensive                               services
                                             periodic MDT                                   across LHC
2. Tariff/PbC                                                        2. Improved access
                                             assessment, in
                      2. Staff                                       to appropriate local
                                             primary care setting
                      education,                                     services               2. Improve and
                      training &                                                            maintain
3. Public Sector                             3. Satellite tertiary
                      development                                                           clinical
Agreement                                    care (resistant RA /
target for care                              Biologics) clinics in   3. Fewer               outcomes
plans                3. Revised              Primary Care            unnecessary follow
                     DMARD                                           ups. Freed
                     Protocols                                       outpatient capacity    3. Promote
                                             4. Enhanced RA
4. Modernising                               knowledge & clinical                           greater patient
Information                                  skills in Primary                              self-
management &         4. Care records /       care                    4. Integrated          management
Technology           communication                                   services for
                                             5. MDT shared Care      patients
                                                                                            4. Develop
                                             record
                                                                                            links with the
5. Workforce         5. Day Case
                                                                     5. Improved            voluntary
Development          Review                  6. Day case care
                                                                     communication          sector, and LA
                                             repatriated from
                                                                     along whole patient    where
                                             Leeds into HRI
                                                                     journey                appropriate
                     6. Self-care &
6. PPI / EPP /                               7. EPP type training
                     Patient
Third Sector                                 for patients &
                     Information
provision                                    information for Pts                            5. Improve
                                                                     6. Patients’
                                             & carers                                       patient & carer
                                                                     empowered and
                                                                                            experience
                                                                     enabled to self-care
                                             8. Web resource for
                                             Primary care & RA
                                             patient community
     Six Workstreams Identified
1. Model of Care
2. Workforce Development and Training
3. Revised Treatment Protocols
4. Biologics / Day-case Service in CHFT
5. Improved Care Records and
   Communication
6. Improved Patient Self-care and
   Information Services
     Dissemination of Results
• If successful this service transformation
  could be applicable
  – To other Rheumatology services
  – To other Specialist Services
• Action Learning and Mentoring
• Do One and Share
• Map of Medicine
       Concluding Remarks
• These are exciting times in Rheumatology
• We (the clinical team) are driving the
  service redesign project
• We are strongly supported by CHFT Exec
  and Divisional Management structures
• We share agendas with local PCTs
• Maybe we will deliver a 21st Century
  Specialist Service that reflects the major
  advances made in disease management
     “Thoughts to Take Away”
• What is your service about?
• Do you really know your own service?
• Do you meet patients needs and
  aspirations?
• What do patients want from your service?
• Do commissioners want your service?
• Do you need to seriously consider redesign
  of your service?
Questions
      Who Should
Drive Service Redesign?
         •Clinicians?
         •Managers?
     •Foundation Trusts?
    •Primary Care Trusts?
How Would You Successfully
   Manage This Service
    Redesign Project?
    •Engagement – getting it right?
         •How could it fail?
       •When should you stop?
How Do You Manage the
 Redesigned Service?
    •What do you measure?
   •How do you disseminate?
    •How do you sustain it?

				
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posted:12/5/2009
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