- Report to the England Council

Representing the England Council, Duncan Forsythe and I, accompanied by Clare Pulford representing the RCP, attended a briefing chaired by Ian Philp and Beverley Malone, around progress with the Evercare project.

There are now ten Evercare chronic care management sites working with frail older people. The background to the project which has been previously set out in the BGS newsletter was again reiterated by Prof Bob Kane from Minnesota.

The goals of chronic disease management are to:

• Manage diseases as efficiently as possible, with a view to reducing the frequency of admissions
• Prevent transition from impairment to disability
• To encourage the patient to play an active role in his/her care
• To work within a cultural sensitive model
• To integrate the care management in all aspects of the older patient’s life

The absolute key to chronic disease management is pro-active monitoring, something that seems to have simply disappeared over the last fifteen years in the UK.

The ten chronic care management programmes are based on a number of principles:

• They identify the high risk population
• They monitor outcomes
• They facilitate fast track care, whether in the community or hospital
• They proactively manage a high risk caseload
• They use systematic tools and processes (for example, risk stratification as well as retrospective reviews of all admissions of their managed patients)
• The focus on the training and education of the staff
• There is an extended GP role, working with qualified nurses

Advanced Practitioner Nurses
At the heart of the initiative there are advanced practitioner nurses who have caseloads of up to fifty patients. In the Bristol example, they identified older patients who had two or more admissions within the last twelve months. They found that 2% of patients were leading to 30% of admissions, and in the same population, 3% was leading to 40% of admissions. They have now identified these key high risk patients, and are starting the interventions with a proactive approach using the advance nurse practitioners. Interestingly, only 30% of these patients were currently known to either district nurses or social services prior to the intervention.

The American experience suggests fewer admissions, higher patient satisfaction and a cost effective model with some shift of care from secondary to primary care. Not surprisingly, the challenges that have been found in the UK are the speed of change, managing to engage all stakeholders, the requirements of Caldicott Guardians, back filling the nurses running the projects and of course, evaluation. One major area where the nurses are getting involved is medication review, working closely with general practitioners.

The leaders of nursing, allied health professional and social services have expressed enthusiasm for these projects. However, key questions remain, most important of which is the evaluation of the pilot studies in the UK. Without that evaluation, it is unlikely to be rolled out beyond the pilot areas. Certainly, this is not about privatisation of the NHS as some people were concerned about last year.

Other issues include the importance of getting rehabilitation input, which is in desperately short supply in many community environments. There are also questions about the sustainability of this model should it be found to be cost effective and rolled out across the country, not to mention the issues about the future role of nurse prescribing.

David Black