High Risk Patients: Sharing Models of Care

Many thanks to all of you who attended the above event in Stirling on 22 May 2007. We hope you had an informative and enjoyable day. The presentations given on the day are available by using the links below. There are a couple which we have not yet received copies of, however if you are anxious to get a copy of these, please get in touch and I will see what I can do.

Steve Kendrick has kindly pulled together a record of the panel discussion [ 37KB] that took place at the end of the day.

Presentations & key points:

Derek Feeley's Presentation - Long Term Conditions (LTCs) are clearly a priority and the big issues are enhancing self-management and assessing those at highest risk of hospital admission.

Bill Mutch's Presentation - Part 1 [ 1,626KB] - Part 2  [ 4,989KB]

There is a need for a systematic approach to LTCs. There are issues around Managed Clinical Networks (MCNs) and hospital specialists becoming more disease specific. In general, the MCN approach should be transferred to LTCs.

Steve Kendrick's Presentation [ 339KB]

SPARRA is changing. It is becoming more real time and will incorporate other data sources. Aim to stratify the whole population in terms of risk at Scotland and local (CHP/CHCP) level.

Gaynor Wotherspoon and Louise Burke's Presentation [ 8,898KB]

The District Nursing case management approach worked in a rural area. There were high levels of satisfaction. However, it is difficult to demonstrate a reduction in admissions. Mentoring and support from GPs is important.

Stuart Cumming's Presentation [  124KB]

SPARRA lists and questionnaires sent to 22 practices and asked about service gaps. Feedback appeared to suggest that GPs were put off by out of date information e.g. the number of deaths etc.

Morag Dorward's Presentation [ 1,956KB]

There are pilots of case management in 3 different localities. Evaluation is awaited. It is important to make best use of existing services. Essentials of case management are coordination, collaboration and communication. Morag also provided a lessons learned paper [ 24KB].

Janette Barrie's Presentation [ 531KB]

12-month pilots are underway with the most effective approaches being rolled out. Training needs for care managers have been identified.

Adrian Baker and Paul Leek's Presentation [ 7,811KB] - Have secured funding for extensive multidisciplinary team to manage people at home, hope to show 15% reduction in bed days.

Chris Johnstone's Presentation [ 57KB]

Case managing 150 patients in Paisley from SPARRA >60% lists. Compare with approx. 150 from the rest of Renfrew. 60% of those identified not known to either Social Work or the NHS.

Amanda Platt's Presentation [ 285KB]

Without the list of individuals from SPARRA, it would have been much harder to identify those patients at risk and the levels of service provided by Health and Social Services.

Janet McCarlie's Presentation [ 147KB]

Likely to need different models of care for the SPARRA cohort e.g. enhanced COPD care for relevant group, and multi-agency support for frail elderly.

Anne Hendry's Presentation [ 4,181KB]

Proposed a learning network across Scotland aiming to share quality improvement, training resources and methodologies.

General points raised during the day - Essentials of case management: coordination, collaboration and communication. Training for case management: motivational interviewing is important. Unlikely that extended prescribing will be required. Need to know about admissions of the managed group early to manage discharge. Some use of 'evercare' red warning flags-to get patients and carers to contact team when certain subtle changes happen.