Learning from practice

Cited in High Impact Changes for Practice Teams, the Improvement Foundation and the NHS Institute Sept 2006 under Change No 2 Improve the management of patients with long term conditions
More details on the Improvement Foundation website at http://www.improvementfoundation.org/View.aspx?page=/topics/health/practice/more_info/high_impact.html

"We have become a smooth running, multidisciplinary team which has put us in a good position for improving patient care, achieving QOF targets and moving forward with Practice Based Commissioning."

This practice took part in NPDT’s Primary Care Collaborative for long term conditions which offered PCTs and individual practices the opportunity to develop systematic approaches to the care of COPD and Diabetes patients.

The practice appointed a Nurse Practitioner and have achieved significant improvements in systematising their Long Term Conditions care. The practice also reviews all patients with emergency admissions to hospital using the discharge information received. Those patients who fit the criteria are visited / seen by the Nurse Practitioner. The other patients are called for a review with the doctor.

As a result they have cut the hospital admittance rate for COPD by nearly 87%.

Data is received on a weekly basis from the PCT regarding all patients who are admitted and are due for discharge. On a monthly basis data is received from the PBC data clerks at the PCT. This data is validated and all patients with 2 or more admittances through A&E have their information passed onto the Nurse Practitioner and the Doctors. The patients then go through a case management process.

Acute visits

When a patient contacts the surgery for a home visit, the Nurse Practitioner discusses with the GPs and between them they decide who will cover the visit. The patient is then assessed to determine the problem. In addition the Nurse Practitioner (NP) has access to GP respite beds and Emergency Social Service Assessment. The NP will discuss with the GP and recommend admission to hospital if appropriate. Basically this is a form of ‘See and Treat’.

General visits

The NP sees all the over 75 housebound patients for their reviews and all the patients on the chronic disease register who are unable to attend surgery. The practice work alongside the community nursing team and over the last winter period the NP took a backlog of the work from the District Nurses and covered the practice patients herself e.g. for flu jabs etc.. The practice is now achieving 100% of the quality and outcomes framework points on COPD, Asthma, CHD and Diabetes, 30.8 of 31 points for Stroke/TIA, is 37.5% below the admissions target (i.e. a reduction of 37.5% on last year) for Cardiology and all elderly patients have received flu and pneumo vacs.