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MANAGING MULTIPLE COMORBIDITIES Kevin Hurrell Crawley GP Clinical Lead for Diabetes CCCG Associate Dean HEKSS Illustrative Case study Mr GB 67yr old first generation immigrant from Pakistan. Has been a leader of his local community. Schizophrenic psychosis diagnosed 1985. On intermittent depot antipsychotic medication for 20+ years Irritable Bowel syndrome diagnosed 1990 Duodenal ulcer 1993 Hypertension 2002 Type 2 Diabetes 2006 CKD 3a without proteinuria 2010 Adverse reaction to ACEI Diagnosed TIA 2012 (doubtful) Drug induced Parkinsonism 2014 Admitted 06/11/2015 following falls. Found to have gone into AF with tachycardia and hypotension. Discharged home on fludrocortisone (to be titrated by GP) , madopar (to be titrated by GP) restarted bisoprolol which patient had stopped (reverted to sinus rhythm) Admitted under section of Mental Health Act within 3 days of discharge Further information on Mr GB • Psychosis causes paranoia, especially mistrust of family and hospital • Concordance always an issue and he blames depot medication for his current • • • • • • • problems Will not take diabetic medication or consider anticoagulation Stopped b-blocker as felt it worsened his Parkinsonism Has annual Mental Health review and care plan update Has annual diabetes review and care plan update Is chased up for QOF reviews etc. CKD,BP, TIA, Medication reviews Usually sees GP 20+ times a year Has a room in the family home: tolerated by rest of family. • I have known him for 30+ years and we have a lot of mutual respect • These multiple comorbidities are a huge burden for patient, family and NHS Some comorbid ruminations: • Diabetes often features on Venn diagram of overlapping comorbidities: • Mental Health • Macrovascular disease • Hypertension • Microvascular Disease • Renal disease • Eye disease • Neuropathy • Foot disease UK National Psychiatric Morbidity Study 2007 • Increased risk of mixed • Impaired quality of life anxiety and depression in patients with diabetes. Hazard ratio=1.7 • Increased risk of developing diabetes in patients with mental health problems: • Lifestyle choices, medication, alcohol • More sick leave/work absence/unemployment • Non-adherence to management plans and poor concordance with medication • Difficulties with self-care of diabetes Stroke risk in Type 2 Diabetes • General practice • Associations: database 2006 • Risk of stroke increased • Hazard ration 2.19 • HR as high as 8 for younger female patients • NB Risk for young women is of course relatively low • Risk increased further with • Duration of diabetes • Smoking • Hypertension • Obesity • Atrial fibrillation Hypertension in diabetes • Up to 75% of patients • Ethnicity and familial with diabetes have hypertension • Hypertension and diabetes share a number of risk factors • Ethnicity and familial history show genetic predisposition to dyslipidaemia and insulin resistance factors also impact on cultural behaviours including lifestyle choices • Increased macrovascular and microvascular risk (alongside risk from hyperglycaemia) Concept of concordant and discordant comorbidities • Concordant • Share common • Discordant • On average we develop aetiological factors • Improvements in one risk area likely to reduce risks elsewhere • Treatment choices increasingly reflect concordant comorbidities e.g. choice of oral hypoglycaemic agents one new long-term condition every 5 years from the age of 55 • Treatment for one LTC may have no impact on other comorbidites • In some cases treatment options conflict e.g. use of l-dopa for Parkinsonism with history of psychosis Hierarchy of comorbidities • Some comorbidities easily eclipse others • End-stage heart failure or terminal illness will reduce the emphasis on tight glycaemic control • But often the hierarchy is less clear, especially when multiple specialties are involved How do we prioritise? • Clinician’s priorities • Patients’ priorities • Often disease specific • Often impact determined • Often future orientated • Often ‘here and now’ • Often driven by ‘quality • Often limited by the ‘burden indicators’ and targets (including financial) • Often results in ‘summative interventions’: more and more medications and appointments of treatment’ • Often results in ‘reductive behaviour’: patients become less and less concordant with medication and also feel disempowered Scale of the challenge • The 15 million people in England with long term conditions have the greatest healthcare needs of the population (50% of all GP appointments and 70% of all bed days) and their treatment and care absorbs 70% of acute and primary care budgets in England. • It is clear that current models of dealing with long term conditions are unsustainable. Rather than people having a single condition, multimorbidity is becoming the norm. • The number of people with 3 or more long term conditions is set to increase from 1.9m to 2.9m by 2018, and this will be associated with an extra £5bn p.a. spend. How might we rise to this challenge? • Patient-centred • Shared clinical consultations • ‘No decision about me without me’ • Truly agreed management plans which respect and empower patients where and when possible information across specialties/GP/commu nity care…and shared with patient. • The Care Plan ideal • But this is not easy! House of Care Paradigm • • • • • • • Single condition services: services dealing with single conditions only and adopting single condition guidelines (with attendant dangers of polypharmacy, and excluding an holistic approach to service users). Lack of care coordination: people being unaware of whom to approach when they have a problem, and nobody having a generalist’s ‘bird’s eye’ view of the total care and support needs of an individual. Emotional and psychological support: in particular, a lack of attention to the mental health and wellbeing of people with ‘physical’ health problems (as well as failure to deal with the physical health of people with mental disorder as their primary long term condition). Fragmented care: the healthcare system remaining within its own economy, and not being considered in a whole system approach with social care or other services important to people with long term conditions (e.g. transport, employment, benefits, housing). Failure to support people with ‘more than medicine’ offers as provided by, for example, third and voluntary sectors. Lack of informational continuity: care records which can’t be accessed between settings, or to which patients themselves don’t have access. Reactive services, not predictive services: failure to identify vulnerable people who might then be given extra help to avoid hospital admission or deterioration/complications of their condition(s). Lack of care planning consultation: services which treat people as passive recipients of care rather than encouraging self-care and recognising the person as the expert on how his/her condition affects their life. Essentials of the model • The House model (derived from the Chronic Care Model of Ed Wagner, and the Diabetes UK Year of Care project is useful for drawing together the building blocks of integrated care to incorporate the essential elements of continuity: • Informational continuity: by which people and their families/carers have access to information about their conditions and how to access services; health and social care professionals will have the right information and records needed to provide the right care at the right time. • Management continuity: a coherent approach to the management of person’s condition(s) and care which spans different services, achieved through people and providers collaborating in drawing up collaborative care plans. • Relational continuity: having a consistent relationship between a person, family, and carers and one or more providers over time (and providers having consistent relationships with each other), so that people are able to turn to known individuals to coordinate their care. The nitty-gritty problems to resolve • Holistic, collaborative and integrated care planning is still elusive • Too often care plans ‘sit on the shelf’ • Conflicting priorities and hierarchies remain • All of secondary care remains disease specific • GPs are best placed to integrate care…but GPs’ working structures are out of date….and there are huge recruitment and retention problems What we are trying to achieve in Crawley • Over 95% of patients with diabetes are seen in general practice (very • • • • • • • • • • different to community clinic). Service has run for 12 years. Nurses with special interest at the forefront of the service Quarterly educational and audit meetings across whole town with excellent consultant support Run a ‘low number stop shop if possible’…looking at as many LTCs as possible GP records remain the closest to the holistic ideal Started looking at much more holistic care plans (but visit from House of Care representatives highlighted the difficulties) Anticipatory care-planning essential…not just listing present care package. Increasing use of ‘Share my Care’: OOH/ SECAmb/ Trust Trying to influence commissioners to think beyond single year funding Trying to work with Community Trust to improve Proactive Care Trying to refine our data on patients at high risk of admission Trying to use IT within care-planning….