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					Lorraine Hewitt
Community Advance Nurse Practitioner
Uwch Nyrs Ymarferydd
District Nursing Service
Chronic Care Management Provision

   To understand the role of the Community
    Advanced Nurse Practitioner (CANP)
   To understand the need for the provision
   To highlight development of infrastructure
    within the practice field
   To highlight problems encountered in the
    practice field

   In Wales the older population is expected to
    grow by 11% by 2020
   Dependency increases with age.
   75% aged 75+ have at least one chronic
   78% of health service expenditure is
    connected to chronic conditions.
      What is a Chronic Condition?

 Definitions
Chronic disease, lifelong diseases/conditions, long
  term diseases/conditions or limiting long term
 Chronic conditions can not be cured only controlled.
 They are life-long and limiting in terms of quality of
 They require self managing skills and ongoing care.
Wanless (2002) Recommendations

   The need for radical         The need to develop
    redesign for health and       capacity outside acute
    social care services          hospital settings

   A robust and evidence        Greater public and
    based approach to             patient involvement
    disseminating best           Stronger performance
    practice and improving        management systems
    system performance
      Welsh Chronic Condition Model

This Model and Framework sets out the broad
  approach to ensure the right service are provided in
  the right place at the right time and meets local
  needs more effectively (WAG 2008)

   Proactive, planned and managed approach,
    identifying and addressing patients’ needs across
    the care pathway.

   Focused on the needs of individuals and where
    possible to prevent or delay chronic conditions
                   Proactive and Planned Management of Chronic Conditions

Information and                   Public and                        Service and            Monitor
Data Analysis                    Patient Needs                      Support                Evaluate
                                                        Service example….
         High Risk Patient                      Level    Case Managed               QUALITY
         Data                                     4      Services social and        ASSESS
         – Case Management                  Level 3      other care
                                           High Risk     services                        Performance
    Secondary/ Social Care                Management        Network Based Service        Management
    Information                                             Social/ voluntary outreach
                                                            Clinics/care GPWSI /Specialist Evaluation
                                                            Nurse, Specialist Service
                                            Level 2
                                                                                   Public/Patient Consultation
                                          management                         Practice Base Service
    Primary / Social Care Data,                                              Self care and EPP
    QOF Patient Data                                                         Annual review, Lifestyle support

                                            Level 1
                                                                                Health Improvement-
      Population             Primary Prevention & Health Promotion
                                                                                Self care, lifestyle support
      Data                                                                      Target intervention
Proactive and Planned Management of
         Chronic Conditions

   Level 4 initially targeted through hospital
    discharge monitoring however CANP’s found
    either patients very ill or already on revolving
    door and difficulty breaking therefore now
    targeting high level 3 prior to acute hospital
    admission but high users of unplanned
    primary care
        Community Advanced Nurse
          Practitioner Chronic Care

Is a Registered Autonomous Nurse Practitioner
working in the generic primary care field with
an additional advanced clinical skills qualification
   (Masters level)

which enables them to assess patient’s and carers’
with in their own homes to plan appropriate service in
order to optimise care options and improve patients
quality of life.
      Aim of Community ANP Role

   To co-ordinate and deliver skilled evidence based
    nursing care sustaining patients within their own
   To promote and teach self care wherever possible
    leading to personal independence.
   To facilitate safe and effective discharges from
    hospitals and prevention of inappropriate admissions
    by improving interface between primary and
    secondary care
   Reduce unplanned GP and OOH care
   Improve concordance with medication
    Knowledge & Skills Framework of Post

   MSc Advanced Clinical Practice

   Take a complex History

   Perform a Physical Examination: Inspect, Palpate, Percussion,

   Form Differential Diagnosis

   Form a clinical management plan

   Order and respond to appropriate Investigations

   Independent Prescriber

   Operational policy
   Advanced Nurse Practitioner Working
   Chronic Conditions – Patient Survey
   Database of interventions and outcomes of
   Integrating through educational programs of
    existing District Nursing staff

   District Nurses team      Family members
    members                   Social Services
   General Practice          Specialist Nurses
   Case Finding              Self
   Hospital – Acute &        Hospice
    Community                 Occupational Therapy
   Residential Home          Physiotherapy
Following Referral the patient can expect:

   A personalised assessment
   Acute intervention to stabilize condition
   Education package to improve out comes
    and self care
   Empowerment
    Effective care management leads to:

   Facilitating safe and timely discharges
   Preventing breakdown of care packages
   Reducing readmission rates
   Preventing ill health/accidents which may
    precipitate admission or moving to
    residential/nursing care setting
   Increase patient’s independence
     Types of activities undertaken

   Cardiac & COPD are the main chronic
    disease problems seen with Co morbidities
   Main problems identified in practice supports
    others findings of non compliance to
    medication due to multiple factors e.g. out of
    date medication, equipment, poor knowledge
    of medication, interactions and lack of
    motivation, improvement in health
        Developing documentation

  Advanced nursing assessment forms
Essential to incorporate medical domain
Used in conjunction with Unified assessment
Documentation is an important characteristic of
the CANP’s role that is shared between
professionals as a communication tool that can
be integrated across the spectrums of care
promoting continuity of care.

     Name & address:         NHS no:
     D no:        DOB:
     Telephone        GP Name & address:
     Presenting Complaint:
     History of presenting Complaint:
     Patient perspective/expectations/motivation
     Assessed by:                 Date:

     Medication on admission
     to caseload
      Allergies and drug reactions /interactions
      Personal History Smoking/Alcohol consumption
      Family History
      Social History
      Past medical and nursing history
      General Appearance, Observations
CARDAIC SYSTEM                   Palpation:
Inspection:                      Pulse: radial
              Cardiac System
Any observable pulsations: Y/N   (rate, rhythm, character, volume)
Symmetry of movement: Y/N        JVP:
Any retractions or heaves: Y/N   Presence of peripheral pulses:
Finger Clubbing: Y/N             Right radial       brachial
Epigastric Tenderness: Y/N       Carotid            femoral
Central Cyanosis: Y/N            popliteal          posterior tibial
Peripheral Cyanosis: Y/N         dorsal pedis
Weight                           Left radial      brachial
                                 Carotid           femoral
                                 popliteal         posterior tibial
                                 dorsal pedis

Heart sounds Normal: Y/N         Position of Apex:
Heart murmur: Y/N                (size, rate & rhythm)
Cardiac Bruits: Y/N

Oedema: Y/N                      Level of oedema:

B/P Standing        Sitting      Previous History of leg ulcers: Y/N
Right                            Comments
Left                             Previous Doppler assessment: Y/N

Episodes of chest pain: Y/N      Skin ( Colour, texture, temp, sensation, itching, rashes)
Radiating: Y/N
Description of Pain:
                                                    RESPIRATORY SYSTEM
Inspection:                                                Capillary Refill≤ 3 secs: Y/N
Skeletal deformity: Y/N                                    Finger Clubbing: Y/N
Symmetry of movement: Y/N                                  Weight loss: Y/N
Use of Accessory Muscles: Y/N                              Pulse:
Able to talk in sentences: Y/N                             (rate, rhythm)
Signs of Cyanosis: Y/N                                     B/P
Signs of foreign body: Y/N                                 Palmer Erythema: Y/N
Deviated Trachea: Y/N                                      Glossitis: Y/N
Position of the mediastinum                                Lymphadenopathy: Y/N
Flapping tremor: Y/N                                       Recent Foreign Travel: Y/N
Signs of Anaemia: Y/N                                      Comments
Pain: Y/N

Percussion:                                                Presence of Other Breath Sounds
Right Normal Flat Dull Resonant Hyper resonant             (crackles, inspiratory wheeze, expiratory wheeze, pleural rub)
Tactile/vocal Fremitus normal Y/N                          Left       Right       Left   Right
Left Normal Flat Dull Resonant Hyper resonant
Tactile/vocal Fremitus normal Y/N

Auscultation:   Equal                                      Oedema: Y/N
Right Normal/ Reduced/Bronchial Breathing/ Silent          SpO²:
Left Normal/ Reduced/Bronchial Breathing/ Silent           Resp Rate:     PEFR:
                                                           MRC Dyspnoea Scale Grade:
Smoking History:                                           Sputum
Current Smoker: Y/N                                        Haemoptysis: Y/N
No Per a day:                                              Colour:
Pack year score:                                           Viscosity:
Receiving cessation intervention: Y/N                      Able to expectorate:

Inhaled Therapy: Y/N                                       Long Term Oxygen Therapy: Y/N
Inhaler: Y/N                                               Short Term Oxygen Therapy: Y/N
Spacer: Device Y/N                                         Litres per min:
 Nebuliser: Y/N                                            Mask Type
Technique observed: Y/N                                    Hours per day:

      Inspection:                                 Comments
      Facial Palsy: Y/N
      Obvious limb weakness: Y/N
      Normal Gait: Y/N
      Alert: Y/N
      Balance Standing Sitting

      Mini Mental State Performed: Y/N            Cranial Nerve Function:
      Score                                       I.XII intact: Y/N
      New Speech Impediment: Y/N                  Comments:
      Appropriate Appearance and Behaviour: Y/N
      Able to follow simple instructions: Y/N

      Five Areas of Sensory Function Assessed     Motor Function Assessed:
      Pain: Y/N                                                       Right     Left
      Light Touch: Y/N                            Normal Muscle Tone: Y/N      Y/N
      Vibration: Y/N                              Normal Muscle        Pos     Pos
      Position: Y/N                               Strength:            /Neg    /Neg
      Discrimination: Y/N                         Rombergs Test:       Y/N     Y/N
      Comments:                                   Nose to Finger:     Y/N      Y/N

      Reflexes Assessed                           Reflexes Comments: (score)
      Biceps: Y/N                                 Right               Left
      Triceps: Y/N
      Patellar: Y/N
      Ankle/Achilles: Y/N
      Planter response: Pos neg

Ears                              Ear Examination
Hearing loss: Y/N                 Foreign Bodies: (Rt) Y/N (L) Y/N
Pain: Y/N                         Colour of Cerumen (Rt)         (L)
Tinnitus: Y/N                     Any inflammation: (Rt) Y/N (L) Y/N
Dizziness: Y/N                    Structures observed Comments :
Discharge: Y/N
Nose                              Nose Examination
Stuffiness: Y/N                   Colour patency of nostril:
Nasal Discharge: Y/N              (Rt)                  (L)
Epistaxis Y/N                     Pain on palpation: Y/N
Symmetry: Y/N                     Swelling of sinuses: Y/N
                                  Pain when sinuses palpated: Y/N
Throat                            Throat Examination
Bleeding: Y/N                     Uvula/Oropharynx pink and moist: Y/N
Redness: Y/N                      Movement observed Y/N
Ulceration: Y/N                   Tonsils Pink no hypertrophy: Y/N
Swelling: Y/N                     Exudate/inflammation: Y/N
Halitosis: Y/N                    Lymph Nodes Palpated : Y/N
Exudate: Y/N                      Comments
Debris : Y/N                      Bruits present: Y/N
Able to swallow own saliva: Y/N
Own teeth: Y/N
Dental caries: Y/N
   Diagnosis (Main Problems)
   Initial Management
   Investigations
   Include Normal base line for individual and new investigations
   HB                     K+                          ECG
   WBC                    Urea                        Chest X ray
   Platelets              Creatinine                  CT scan
   CRP                    Glucose            Other
   Na                     Ca+                         C enzymes
   TFT                    LFT                         CBG
   Wt.                    Ht.                         BMI
       Medicine Management sheet

 Pharmacist model adapted to our field of
 INP communication sheet
Used to inform other members of the MDT of
  drug changes and prescriptions if unable to
  enter on computer records
                Observation forms

   Observation forms are used to compare
    episodes of care, track and assist recognition
    patterns and cues to instruct and shape

           Right Normal Flat Dull Resonant Hyper resonant
           Tactile/vocal Fremitus normal Y/N
           Left Normal Flat Dull Resonant Hyper resonant
           Tactile/vocal Fremitus normal Y/N
Presence of Other Breath Sounds (crackles, inspiratory wheeze,
expiratory wheeze, pleural rub)

Auscultation:    Equal
Right Normal/ Reduced/Bronchial Breathing/ Silent
Left Normal/ Reduced/Bronchial Breathing/ Silent
Resp              Temp
Weight        colour     sputum
Date& Signature
      Patient Problems /Focus sheet

   Based on care of the dying documentation
   It was designed to use quickly to identify
   Aids recognition
     Patient Problems /Focus sheet

• Goal 1: Educate Patient self management of their long
  term condition
• Patients attitudes and anxieties regarding their long term
  conditions are addressed
• Information on coping strategies provided
• Educate Patient on disease management
• Provide information relating to Health Promotion
• Educate Patient on breathing techniques
• Patient performance scoring
• 0=Fully active 1= Restricted in physical strenuous activity
  2= Ambulatory, self caring, unable to work 3= Capable of
  limited self care 4 = Unable to carry out self care
        Goal 2: Management of long term conditions
                  and related symptoms

•   Patient able to cough and self expectorate
•   Referral to specialist services as appropriate
•   Educate Patient to monitor chest pain
•   Severity of pain recorded on pain assessment tool
•   Educate Patient on oedema management
•   Educate Patient on complications relating to diabetes
•   Encourage uptake of annual health checks
•   No identified changes to sleep pattern/Mood
        Goal 3: Medicines Management

• Educate Patient/carer on correct use of medications
• Educate Patient/carer on correct use of GTN spray
• Medication reviewed in last 6 months
    Goal 4: Patient is supported to remain in a community

•   No deterioration in patient’s nutritional status identified
•   Personal and domestic needs met
•   No deterioration in patient’s skin integrity identified
•   Patient understands need for rest and relaxation during
    times of exacerbation of disease process
•   No deterioration in patient’s mobility status identified
•   No changes identified to patients normal elimination
•   No changes identified to by patients carer
•   Observations with in normal limits for individual patient
Multidisciplinary communication

   Advanced Nurse Practitioner Referral Form
   Episode of care summary
   Transfer of care summary
   Patient information sheet
                   Pit Falls

   Poor understanding of role

   Resistance to change from both
    professionals and the public

   Ownership

   Name Case manager
                  Patient Survey

   Findings
   Average Age 70
   Minimum Age 21
   Maximum Age 88
   48% N=29 Felt that their understanding of
    their health had improved a lot since seeing
    the Community Case Manager
   66% reported improved changes to their
    quality of life?

   76% reported change in how their healthcare
    was organised?

   93% claiming contact benefited them
    Shaping the future Service Development

   Expanding Service training Advanced Nurse
   Associate Practitioner
   Clerical support
   Increase Knowledge and Skill within the
    District Nurse Service
   Thank you very much for listening

   Any questions??

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