Chronic Disease Management

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Practice Leads

  • Doctors: Liz Hamblin
  • Nurse: Zoe Booth

Date Reviewed

14 April 2016

Date of Next Review

September 2017

Why managing chronic disease is important

There is a growing epidemic of chronic disease in the UK due to tobacco use, unhealthy diets, physical inactivity and other risk factors.   Whilst it is important to prevent these diseases from happening in the first place (which we are also trying to do – termed ‘primary prevention’), it is also important to prevent them from getting worse or causing other problems in patients who already have them (this is called ‘secondary prevention’).  With good management of chronic diseases, people can live longer.

A good example of this is diabetes – if you don’t manage a patient with diabetes properly, their diabetes will get worse, and over a number of years, they may end up with kidney failure, blindness, heart attacks, strokes, gangrene of the legs and so on.  And then they end up being hospitalised.   If we treat a patient’s diabetes and get their sugars under good control, we can stop them from getting most of these things and reduce unnecessary hospitalisation.  Clearly, this is very good news for the patient (as it stops their lives from being hampered by illness, infirmity and disability) but it’s also good for the NHS in general because the cost of treating these  complications and subsequent hospitalisation would otherwise be very expensive.

Offering good co-ordinated care that is in line with national and local guidance reduces the fragmentation of care and also reduces the risk of clinical error (including medication errors) and thus litigation risk.  In summary, by optimising the management of a patient’s chronic disease, EVERYONE is a winner.

This drawing is from a lady with a long term condition (LTC).  The green line is her managing her chronic (long-term) condition.   The red bars indicate the times when she has to make contact with a health professional/service.   As you can see, this patient is an expert of her condition and she manages her condition on a day-to-day basis by herself.   It’s important that her health professionals support her when things are a bit rough (the red bars) and help her get back to the more stable green line.     But we can only do this with patients if we invest time in them by….

  1. educating them about their illness(es)  (filling in the gaps in their technical knowledge)
  2. giving them confidence with self-management
  3. facilitating shared decision making.

If we don’t do this, then we simply create dependancy on us (which in turn creates unnecessary pressure on GP and hospital services) but more importantly it is ethically unfair on patients because it limits THEIR freedom and THEIR choice about THEIR own lives.   Would you feel happy if this was taken away from you?

patient with a chonic disease

What are we aiming for? (The 4 stages of Care Planning)

 

FAQs

EXAMPLES OF CHRONIC DISEASE

  • Hypertension (high blood pressure)
  • Angina/Heart Attacks
  • Heart Failure
  • Strokes
  • Diabetes
  • Asthma
  • COPD (Chronic Obstructive Pulmonary Disease)
  • Renal (Kidney) Failure
  • Osteoporosis
  • Cancer Care
  • Drug & Alcohol misuse
  • Mental Health Disorders like Depression, Anxiety, Bipolar disease, Schizophrenia and so on.

HOW DO WE ACHIEVE OPTIMAL CHRONIC DISEASE MANAGEMENT?

The management of chronic disease requires a systematic, proactive and comprehensive approach – in other words, tackling the problem from many angles rather than just one way (e.g. medication alone).   We achieve this comprehensive approach through

  • Keeping a register – of the various chronic diseases and our patients that belong to them.
  • Reveiwing these patients periodically and checking concordance with medication (through medication reviews).
  • Having named care co-ordinators for some of them – particularly those with complex medical needs or multiple chronic diseases (i.e. those with a high-medium risk of clinical deterioration; The Kaiser ‘risk-pyramid’ model).   In such circumstances, the patient will have an assigned GP care co-ordinator.  In many high-risk cases, a Case Manager (a very senior and highly qualified community matron) will also be involved – checking in on the patient at regular intervals and also on an as and when basis with a view to
    1. improving health,
    2. coordinating care from multiple providers (to reduce fragmentation and duplication of care)
    3. reducing the use of health care services and
    4. support patients and their carers
    5. promoting self-care and providing the appropriate material.
  • Following national (National Service Frameworks) and local protocols (Local Enhanced Services)  to help ensure that every patient is looked after in the optimally advised way (evidence based practice of medicine).
  • Optimising diet, phsysical exercise and healty living choices.  Our nurses, doctors and health trainers will provide patients with this information.  There’s a lot of written material available too – either from the surgery or from other parts of this website.   We even provide access to weight management clinics (as and when they are available).
  • Blood tests and other investigations periodically as advised by national experts.  See this link here of what certain groups of patients should have done and when: chronic disease – bloods tests and reviews table.doc
  • Risk-stratification tools and electronic disease registers- to identify patients who are at high risk of deterioration and subsequent hospital admission.   And then putting measures in place to achieve greater stability and control (named doctors, case manager, coordinating care, liaising with outreach clinics to optimise care, patient education and so on).
  • Multidisciplinary team working – working with health professionals with different specialties to help optimise care.  If we were ever in doubt about the management of a patient, we would seek advice from colleagues, expert GPs and hospital specialists in the field.
  • Specialised clinics for some of the clinical problems above – available at our surgery or in a surgery nearby.  For other conditions, most GPs are well versed in the optimal pathways for management.
  • Promoting self-help where we help patients to understand THEIR condition so that THEY can start being involved in managing THEIR own conditions in order to get some control of THEIR own lives.  We will help patients develop a plan for self-management at home (currently in place for a number of our patients with COPD).
  • Effective clinical information systems – ensuring that we record important things in the clinical notes so that care us properly co-ordinated and information shared where it needs to be.

FEATURES OF A GOOD CHRONIC DISEASE MANAGEMENT PROGRAMME

(after Velasco et al, 2003)

It should

  1. provide comprehensive care – multidisplinary care for entire disease cycle
  2. provide integrated care, care continuum, coordination of the different components
  3. be population orientated (defined by a specific condition)
  4. involve active patient management tools (health education, empowerment, self-care)
  5. be evidence-based on guidelines, protocols, care pathways
  6. involve information technology, systems solutions
  7. embrace continuous quality improvement

Our chronic disease pathways at Ashcroft include these 7 things.    Chronic disease can rarely be treated in isolation. Many patients have more than one chronic disease and at Ashcroft, we try and look at the whole picture, rather than in fragmented parts.

The other thing we are keen on at Ashcroft Surgery is self-care.  By ensuring that knowledge of their condition is developed to a point where they are empowered to take some responsibility for its management and work in partnership with their health and social care providers, patients can be given greater control over their lives. Self-management programmes can be specifically designed to reduce the severity of symptoms and improve confidence, resourcefulness and self-efficacy.

WHAT ARE WE EXPLORING FOR THE FUTURE?

  1. The use of remote monitoring technologies (telehealth).
  2. The use of Expert Patient Programmes.