Aspiring to Clinical Excellence

IN GENERAL PRACTICE

PRACTICE TEAM BRIEFING – September 2014

You may have heard your GPs or Practice Manager talking about the ACE Excellence Programme. Three Sutton Practices, namely Manor Practice, Vesey Practice and Sutton Park Surgery, recently joined together to bid to become one of the Pilot collaborative for the Ace Excellence programme. Unfortunately we were unsuccessful in the first round, but resubmitted our case and were accepted to take part in the second round as Early Adopters of the programme.

This document is designed to give you a general overview of what the ACE programme is about. If you require additional information or wish to seek clarification on any points contained in this briefing, please email your queries to . Alternatively you can speak to your practice ACE Lead:

Manor Practice – Dr Howland

Vesey Practice – Dr Garbutt

Sutton Park Surgery – Dr Mantella

If you wish to view the complete ACE: Excellence Early Implementers Service Framework, please let Ellen know and she will email a copy to you.

The aim of the ACE scheme is to look at how we can improve the management of long term medical conditions in General Practice with the ultimate aim of reducing emergency admissions. For this to take place, our practices have joined together to enable us to share our experiences and best practice and to provide the full range of services for patients.

The overall rational for introducing the ACE Excellence scheme is to create a fully integrated health and social care system that ensures every patient in Birmingham receives proactive, joined up care, supporting them to live as independently as possible in the most appropriate setting and achieving the best outcomes.

In order to achieve this we will have to ensure that every stage of the patient journey is improved and works effectively. The ACE Excellence programme has three key priorities:

1. Improving further the quality of general practice across the city, making a comprehensive and universal offer to our patients, ensuring that all patients in five years are receiving the same high quality of care that the best now receive;

2. Transforming quality and access to mental health services; and

3. Transforming the way in which our urgent care system currently operates, by improving processes at the front and back doors of our hospitals, and building capacity in primary care (by which we mean general practice, community health services, mental health services outside of hospital, and social care).

ACE Components – in brief

Holistic Care and Diagnosis of patients with Long Term Conditions.

Aims

  • Holistic patient centred care management of multiple LTCs which frequently co-exist.
  • Improved outcomes in terms of reduced morbidity and long term complications, increased life expectancy through better control of optimal evidenced based targeted treatment and interventions
  • Reduction in emergency admissions for diabetes, heart failure and COPD
  • Reduction in first OPD for diabetes, heart failure, COPD and asthma.
  • To deliver the Integration of specialist skills into an integrated primary care team approach to disease management.

Diabetes and Pre-Diabetes

Diabetes

Delivery to over 90% of patients all eight diabetes care processes. The evidence is that this reduces future significant complications. Currently under 50% of diabetic patients in Birmingham receive all eight. These eight care are:-

  • five risk factors (weight (BMI), blood pressure, smoking, glucose levels (HbA1c), and serum cholesterol)
  • Three tests for early complications (laboratory urine micro albumin: creatinine ratio, serum creatinine and foot nerve and circulation examination).

Pre-Diabetes

Identification of a cohort of at risk patients, delivery of lifestyle advice and referral to appropriate lifestyle services such as exercise. The more additional risk factors an individual has the more likely they are to develop diabetes. The progression to diabetes for people with IGT is 6-10% per year and for individuals with both IFG and IGT, the cumulative incidence of diabetes may be as high as 60% in 6 years Diabetes UK –pre diabetes

Recent data from the US Diabetes Prevention Program (DPP) suggests that an HbA1c ≥ 6.0% approximately doubles the rate of progression to Type 2 diabetes in people with other risks such as obesity. The recommendations focus on two major activities:

  • Identifying people at risk of developing type 2 diabetes using a staged (or stepped) approach. This involves a validated risk-assessment score and a blood test – either the fasting blood glucose or the HbA1c test to confirm high risk.
  • Providing those at high risk with a quality-assured evidence-based, intensive lifestyle change programme to prevent or delay the onset of type 2 diabetes

Cardiology

Diagnostics in General practice

  • ECG –recording and interpretation
  • Ambulatory blood pressure monitoring for diagnosis of hypertension- 24 hour or 7 day recording
  • Heart failure up titration of treatments to effective tolerated doses in all patients Case management, with possible tele-monitoring, for patients with severe heart failure or admissions

The three practices have purchases Microlife Watch ABPM machines to help support this indicator and training has been arranged.

Respiratory

Diagnostics and interpretation in General practice

  • Spirometry

Management of COPD and Asthma.

  • Patients at risk of admission or severe exacerbations provided with self management plans and rescue packs as appropriate.
  • Patients should be given easy access to advice from GP practice in the event of an exacerbation.
  • Optimised treatment

The impact of exacerbations should be minimised by:

  • giving self-management advice on responding promptly to the symptoms of an exacerbation
  • starting appropriate treatment with oral steroids and/or antibiotics
  • use of non-invasive ventilation when indicated
  • use of hospital-at-home or assisted-discharge schemes. [2004]
  • Ensure multidisciplinary working , involvement of ACMs.

Written action plans, given as part of structured education can improve outcomes such as self-efficacy, knowledge and confidence for people with asthma, particularly for people with moderate to severe asthma whose condition is managed in secondary care. For people with asthma who have had a recent acute exacerbation resulting in admission to hospital, written personalised action plans may reduce readmission rates.

Shared care For Long term conditions.

  • Shared with Secondary care for patients suitable for ongoing monitoring and prescribing in General Practice
  • Covers cytotoxic drug prescribing such as DMARDS for rheumatological, gastroenterological and respiratory conditions,
  • Must be underpinned by shared care agreements and protocols
  • Also covers ongoing monitoring of some stable conditions, within clear criteria for monitoring and re referral to secondary care

Integration of community teams into General practice and delivery of holistic care

Aims

  • to integrate community teams fully into General Practice setting,
  • support enhanced services to patients over 75 and those patients receiving case management including patients near the end of life
  • identification and support for patients with dementia and their carers

Outcomes

  • True integrated nursing and allied health professional teams delivering care to a practice population both in surgeries and in patients own home as appropriate
  • Improved continuity of care to patients
  • Reduction in duplication of services
  • An ability for practices to define teams on the basis of local population health needs and configure this around the patient.
  • Pilot to explore integration of teams, models of delivery and working, job plans, relationship and local accountability of BCHC.
  • Pilot also to explore integration of social worker into the team
  • Integration of specialist community services to support delivery of holistic care
  • Identification and case management via the integrated team approach with a focus on prevention, enablement and self-management
  • Care and residential home support with an outcome of reducing admissions by 30%.
  • Achieve dementia diagnosis rates to 67% and support carers through ACE foundation

Involvement of practice teams

For us to succeed and improve the patient experience and the services we offer, we need everyone to be fully committed to the delivery of the ACE Excellence scheme.

Please come forward with any ideas you may have for service delivery or any problems / issues you have identified so that we can plan future improvements.

Following our initial meeting in August, the following early actions were identified:

  • Mental Health – It was agreed that all practices should engage in the following:
  • Review patients attending A & E with mental health issues
  • Ensure effective use of Birmingham Healthy Minds and Open Door Youth Counselling
  • Use of enhanced template for referrals.
  • Asthma – practice use of management plans.
  • Pre-diabetes – It was agreed that this was an area that needed a fair amount of input as the provision seemed to vary quite significantly between practices. Looking at an email sub-group.
  • DMARDS – Discussion regarding repeat medication and blood monitoring. The group is looking at developing a policy / protocol to move DMARD medication from repeat to acute and not issue unless monitoring has been done.
  • Dementia & Carers –
  • Carers register – actively recording carer information / contact details on clinical systems.
  • Looking at a repository of information for carers of patients with dementia and carers in general.
  • Leaflet / handout of local help groups and information to be developed – this has already been circulated to practices.
  • Information on bereavement services

Further information and updates will be sent to all practice clinical teams as we progress with the ACE Programme over the coming months. If you wish to contribute or have any communication you wish to put forward, please let Ellen have the details –

September 2014

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