What does the CDM LES 2014-15 mean to you?
As has been described over the past few months, we are on an improvement journey, one which facilitates a person centred approach and, over the next year or so, one that assists and enhances supported self management. The new and revised templates will support this as they will be more user friendly with less text and greater clarity. This will allow you to deliver individualised, high quality, evidenced based care. Many of these changes have been in response to your requests through 1:1 support, feedback following the 2013 template launch and the PN IT survey. In order to support the ethos of a person centred approach, and to take into account your feedback, the LES business rules have been significantly reduced and simplified for 2014/15.
The following box shows what needs completing for payment purposes:
CDM /- Chronic Disease Management Annual Review completed
- Record which disease/s completed
Health Determinants /
- Assess current status
- Agenda setting complete
- Readiness to change (including a 1,2 or 3) in the measure box
- Goal setting agreed
What does this mean?
The CDM clinical template now has only two boxes to complete for payment purposes in the last section. The four payment areas within the health determinants section remain unchanged.
Please note: Every stage above needs completing for full payment, no partial payments will be made. This will be clear within the LES payment screens.
You will notice the content of the clinical sections have changed in line with current evidence and MCN guidance. You will find new questions to screen for anxiety, depression and "coping" within the Emotional Wellbeing Section. These mental health conditions are very common in patients living with long-term conditions, and are associated with poorer health outcomes and reduced quality of life.
Workforce
In ourexperience, Practice Nurses are the primary source of workforce used for the CDM LES programme. We will issue further guidance on the role of HCSW’s within the CDM LES contract during April 2014.
It is essential that practitioners involved in the CDM LES Programme have the appropriate competences and skills required to deliver this. Our current local and national evidence tells us that we must improve on:
- patient centeredness
- brief interventions
- ways of working with patients who have multi-morbidity
- use of decision making tools
- training and support to practitioners
These changes and direction of travel require a different approach in supporting General Practice to deliver the CDM LES Programme. These are outlined below:
A Help Desk will be available from 22nd April 2014. We know from our experience last year that this was invaluable. To improve on this service we will have a designated phone number which is manned by Primary Care Support Nurses (PCSN) from the Practice Nurse Advisor’s team. We can also use WebEx to enhance this support as necessary. (The flier has already been issued).
Local Small Group Learningevents will be available in every CH(C)P area from 29th April 2014 (booking forms have already been issued). We will make these sessions practitioner led which will allow you the opportunity to raise any issues from a consultation and template perspective. All groups will have access to the templates to support your discussions.
Health Behaviour Change: to enhance the existing skills of the Practice Nurse, a series of one hour workshops will be locally available approximately one week after the Small Group Learning Sessions. (Booking forms have been issued).
Template Road Test: You can request to use a volunteer patient from our Patient Forum which will give you an opportunity to have a ‘trial’ consultation using the template as a framework or tool to support your consultation. (Details have already been issued).
Mental Health Training:Five sessions have been delivered to date. This training will be evaluated and dates should be advertised in the near future.
Handbooks: A Rationale handbook has been developed to support you within your work place. This will be available electronically and in hard copy format, delivered via the black bag system. IT user guides are being developed for April and a further handbook will be available electronically which will include FAQs and scenarios collated from the small group learning events.
Information Repository: We will provide a Staffnet page which will host all education/training courses and IT resources. This will make it easier for you to remain up to date.
MUST (Malnutrition Universal screening tool) on line training will be promoted from June 2014as nutritional status is particularly important in Heart Failure and COPD.
Learning packages: These are still being developed, particularly around the clinical elements of the Practice Nurse CDM consultation and will be available soon.
Please contact the Practice Nurse Advisors Team for any further information
or call 0141 211 3632
Anne Cochrane
on behalf of Kathy Kenmuir
(Acting Practice Nurse Advisor, NHSGG&C)