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Needs-led management in the community.

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VOL: 101, ISSUE: 48, PAGE NO: 42

Dudley Beacon and Castle Primary Care Trust has designed a proactive model of care that identifies patients with long-term conditions and provides the type of individualised care they require according to their needs.

Dudley Beacon and Castle Primary Care Trust has designed a proactive model of care that identifies patients with long-term conditions and provides the type of individualised care they require according to their needs.

The project grew out of a planned reduction in the number of hospital beds and a desire to reduce the reliance on secondary care services. It aims to increase the provision of care in a primary, community or home environment.

Patients are assessed for the complexity of their needs and then allocated to the level of care they require. A Kaiser pyramid (Fig 1) demonstrates the different levels of care. At the top level (3a), are patients with the most complex needs. They are case-managed by a consultant nurse. Patients assessed as being on the next level (3) also have complex needs, but are managed by case managers who have a district nursing background. On level 2 are patients who are cared for by rapid care teams (previously district nursing teams).

An expert patient programme is run by the patient advocacy and liaison service to help patients manage their own condition. The courses are particularly for patients who are at a lower level of care need, but they are also available for those with more complex needs who would benefit.

Catherine Molineux has been the consultant nurse for the project for the past two years. Before that she worked as an advanced nurse practitioner in general practice. She says that the beauty of the case management approach is that it is 'pure commonsense'. It works, she says, because clinicians, both nursing and medical, were fully involved in developing the reorganisation two years ago.

Although new nursing roles have been created by the scheme, Ms Molineux says that it uses skills that staff at the trust already have. 'It has been about finding new ways of working and about working in a more proactive way,' she says.

Ms Molineux spends 50 per cent of her time looking after a caseload of patients; currently she has 50. Initially, the most complex patients were identified by looking at hospital admission data and seeing those who had frequent admissions. However, Ms Molineux has discovered that this method is not always accurate: sometimes it identifies patients who have had an episode of acute ill health but are not suffering from a long-term condition.

To ensure that all appropriate patients have been identified, she is now also asking GPs to identify their patients with the most complex needs, those who have a high number of GP visits and those who have a high potential of being admitted to hospital.

A simple assessment tool is used to assess the complexity of each patient's needs. Five criteria are used in a tick system: l The number of clinical conditions; l Home circumstances; l Home support; l Prognosis; l The amount of psychological input. Generally, patients managed by the consultant nurse have co-morbidity, whereas those managed by the four case managers tend to have a single disease.

Whatever the complexity of the patients' needs, the approach within the different levels has a similar emphasis. A personal care plan is developed with the patient and carers, which focuses on early intervention. Patients and/or carers are encouraged to contact the appropriate nurse if they are concerned. Ms Molineux explains: 'The service is no longer run as a reactive service; we want to move away from crisis management. We are managing patients in a proactive way through a care pathway. We want to monitor patients with chronic disease, even in a well phase, so that we can detect any early signs or changes.'

As well as helping to prevent patients being admitted, the nurses are taking on new skills to help patients stay at home. For example, they are now giving intravenous drugs in the community to patients with conditions such as cellulitis. Also, they are focusing particularly on patients with chronic respiratory disease who are being managed proactively through a care pathway that has been developed with the acute trust.

Another feature of the service is the way the specialist nurses work. Unlike those in many other areas, they do not have a caseload of patients. Instead, they support and enable general nurses to look after patients with particular conditions. The aim of this way of working is to prevent the deskilling of the generalist nurses.

The system in Dudley encourages holistic care that encompasses both the community and the acute services. Ms Molineux explains: 'We have daily contact with the emergency assessment unit at the hospital. The case managers go on ward rounds with the consultants and assess the patients to see if there are any we can turn round at the front door. If they are admitted, we can follow them through the system and reduce their length of stay'.

The nurses are now trying to have a similar input in the general wards, but this has been met by a mixed reaction. 'Most of the time we are welcomed,' says Ms Molineux, 'but a few of the staff want to hold on to what they do. We need to work on that.'

Some of the community nurses have been daunted by their new responsibilities but, says Ms Molineux, the majority are enthusiastic and motivated by the change in service delivery and by the new opportunities it offers them.

In the future there are plans to develop the model further by integrating more closely with social care and social services as well as further developing relationships with the acute trust.

Case study
Mrs Alice Peters is 84-years-old and lives alone with the support of her son, who also has health problems and is registered disabled. She has chronic obstructive pulmonary disease (COPD) and is partially sighted and deaf. A carer visits her morning and night. She manages to walk around the house but has not been out for several years.

Over the past three years, Mrs Peters had had multiple attendances at A&E, which resulted in frequent admissions.

When the consultant nurse, Catherine Molineux, visited Mrs Peters to assess her, she noted that she had a pattern of going into hospital on a Sunday every couple of weeks. Mrs Peters was then encouraged to contact the consultant nurse when she recognised early symptoms of not feeling well instead of ringing for an ambulance. She consequently did this, and was found to be having a mild exacerbation of her COPD, made worse by her anxiety, but hospital admission was avoided on this and subsequent occasions.

Mrs Peters has now been transferred to the care of the rapid care team. She is able to recognise early signs of a worsening in her condition and can speak to the nurse when she feels anxious. Often the situation can be managed over the telephone; at other times a visit is needed for reassurance and support or she requires treatment.

Mrs Peters now attends a day centre two days a week so that she has some company, an arrangement that helps her son in his role as carer.

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