Download Slide 1

Lorraine Hewitt
Community Advance Nurse Practitioner
Uwch Nyrs Ymarferydd
District Nursing Service
Chronic Care Management Provision
Aims




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
Introduction




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
condition
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
conditions
 Chronic conditions can not be cured only controlled.
 They are life-long and limiting in terms of quality of
life
 They require self managing skills and ongoing care.

Wanless (2002) Recommendations

The need for radical
redesign for health and
social care services

The need to develop
capacity outside acute
hospital settings

A robust and evidence
based approach to
disseminating best
practice and improving
system performance

Greater public and
patient involvement
Stronger performance
management systems

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
arising.
Proactive and Planned Management of Chronic Conditions
Information and
and
Data Analysis
Public and

Service and
Patient Needs
Support
Monitor
Evaluate
Service example….
High Risk Patient
Data
– Case Management
Secondary/ Social Care
Information
Trends
Primary / Social Care Data,
QOF Patient Data
Population
Data
Level
4
Level 3
High Risk
Management
Case Managed
Services social and
other care
services
QUALITY
ASSESS
Performance
Management
Network Based Service
Social/ voluntary outreach
Clinics/care GPWSI /Specialist Evaluation
Nurse, Specialist Service
Level 2
Population
management
Level 1
Primary Prevention & Health Promotion
Public/Patient Consultation
Practice Base Service
Self care and EPP
Annual review, Lifestyle support
Health ImprovementSelf care, lifestyle support
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
homes
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,
Auscultation

Form Differential Diagnosis

Form a clinical management plan

Order and respond to appropriate Investigations

Independent Prescriber
Integration





Operational policy
Advanced Nurse Practitioner Working
arrangements
Chronic Conditions – Patient Survey
Database of interventions and outcomes of
care
Integrating through educational programs of
existing District Nursing staff
Referrals





District Nurses team
members
General Practice
Case Finding
Hospital – Acute &
Community
Residential Home







Family members
Social Services
Specialist Nurses
Self
Hospice
Occupational Therapy
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.

ADVANCED NURSE PRACTITIONER
ASSESSMENT









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
Inspection:
Cardiac System
Any observable pulsations: Y/N
Symmetry of movement: Y/N
Any retractions or heaves: Y/N
Finger Clubbing: Y/N
Epigastric Tenderness: Y/N
Central Cyanosis: Y/N
Peripheral Cyanosis: Y/N
Weight
Palpation:
Pulse: radial
(rate, rhythm, character, volume)
JVP:
Presence of peripheral pulses:
Right radial
brachial
Carotid
femoral
popliteal
posterior tibial
dorsal pedis
Left radial
brachial
Carotid
femoral
popliteal
posterior tibial
dorsal pedis
Heart sounds Normal: Y/N
Heart murmur: Y/N
Cardiac Bruits: Y/N
Position of Apex:
(size, rate & rhythm)
Oedema: Y/N
Level of oedema:
Bilateral/Unilateral
B/P Standing
Right
Left
Sitting
Episodes of chest pain: Y/N
Radiating: Y/N
Description of Pain:
Previous History of leg ulcers: Y/N
Comments
Previous Doppler assessment: Y/N
Comments
Skin ( Colour, texture, temp, sensation, itching, rashes)
RESPIRATORY SYSTEM
Inspection:
Skeletal deformity: Y/N
Symmetry of movement: Y/N
Use of Accessory Muscles: Y/N
Able to talk in sentences: Y/N
Signs of Cyanosis: Y/N
Signs of foreign body: Y/N
Deviated Trachea: Y/N
Position of the mediastinum
Flapping tremor: Y/N
Signs of Anaemia: Y/N
Pain: Y/N
Capillary Refill≤ 3 secs: Y/N
Finger Clubbing: Y/N
Weight loss: Y/N
Pulse:
(rate, rhythm)
B/P
Palmer Erythema: Y/N
Glossitis: Y/N
Lymphadenopathy: Y/N
Recent Foreign Travel: Y/N
Comments
Percussion:
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)
Left
Right
Left
Right
Auscultation:
Equal
Right Normal/ Reduced/Bronchial Breathing/ Silent
Left Normal/ Reduced/Bronchial Breathing/ Silent
Oedema: Y/N
SpO²:
Resp Rate:
PEFR:
MRC Dyspnoea Scale Grade:
Smoking History:
Current Smoker: Y/N
No Per a day:
Pack year score:
Receiving cessation intervention: Y/N
Sputum
Haemoptysis: Y/N
Colour:
Viscosity:
Able to expectorate:
Inhaled Therapy: Y/N
Inhaler: Y/N
Spacer: Device Y/N
Nebuliser: Y/N
Technique observed: Y/N
Long Term Oxygen Therapy: Y/N
Short Term Oxygen Therapy: Y/N
Litres per min:
Mask Type
Hours per day:
NEUROLOGICAL SYSTEM
Inspection:
Facial Palsy: Y/N
Obvious limb weakness: Y/N
Normal Gait: Y/N
Alert: Y/N
Balance Standing Sitting
Comments
Mini Mental State Performed: Y/N
Score
New Speech Impediment: Y/N
Appropriate Appearance and Behaviour: Y/N
Able to follow simple instructions: Y/N
Cranial Nerve Function:
I.XII intact: Y/N
Comments:
Five Areas of Sensory Function Assessed
Pain: Y/N
Light Touch: Y/N
Vibration: Y/N
Position: Y/N
Discrimination: Y/N
Comments:
Motor Function Assessed:
Right
Normal Muscle Tone: Y/N
Normal Muscle
Pos
Strength:
/Neg
Rombergs Test:
Y/N
Nose to Finger:
Y/N
Comments:
Reflexes Assessed
Biceps: Y/N
Triceps: Y/N
Patellar: Y/N
Ankle/Achilles: Y/N
Planter response: Pos neg
Reflexes Comments: (score)
Right
Left
Left
Y/N
Pos
/Neg
Y/N
Y/N
EAR NOSE AND THROAT
Ears
Hearing loss: Y/N
Pain: Y/N
Tinnitus: Y/N
Dizziness: Y/N
Discharge: Y/N
Ear Examination
Foreign Bodies: (Rt) Y/N (L) Y/N
Colour of Cerumen (Rt)
(L)
Any inflammation: (Rt) Y/N (L) Y/N
Structures observed Comments :
Nose
Stuffiness: Y/N
Nasal Discharge: Y/N
Epistaxis Y/N
Symmetry: Y/N
Nose Examination
Colour patency of nostril:
(Rt)
(L)
Pain on palpation: Y/N
Swelling of sinuses: Y/N
Pain when sinuses palpated: Y/N
Throat
Bleeding: Y/N
Redness: Y/N
Ulceration: Y/N
Swelling: Y/N
Halitosis: Y/N
Exudate: Y/N
Debris : Y/N
Able to swallow own saliva: Y/N
Own teeth: Y/N
Dental caries: Y/N
Throat Examination
Uvula/Oropharynx pink and moist: Y/N
Movement observed Y/N
Tonsils Pink no hypertrophy: Y/N
Exudate/inflammation: Y/N
Lymph Nodes Palpated : Y/N
Comments
Bruits present: 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
Urine
Medicine Management sheet
Pharmacist model adapted to our field of
work
 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
decisions.
Percussion:
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
Observations
B/P
Pulse
Resp
Temp
SPO²
Weight
colour
sputum
Date& Signature
Patient Problems /Focus sheet



Based on care of the dying documentation
It was designed to use quickly to identify
problems
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
setting
•
•
•
•
•
•
•
•
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
pattern
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
Practitioners
Associate Practitioner
Clerical support
Increase Knowledge and Skill within the
District Nurse Service

Thank you very much for listening

Any questions??