Sharing our Experiences of Using SPARRA

Rhona GuildPrimary Care Manager

Angus Community Health Partnership (CHP)

NHS TaysidePopulation

Angus Demographics

• Total population 109,320• Lower than Scottish average population

of working age• Higher life expectancy in both men and

women• 0.8% ethnic minority population• All cause mortality and heart disease

mortality lower that Scottish average and cancer mortality amongst lowest in Scotland.

Demographics (continued)

• Proportion of population hospitalised for alcohol or drug related causes amongst lowest in Scotland

• Significantly lower rate of acute admissions

• Lower levels of homelessness• Lower levels of deprivation

(Source: Scot PHO Health & Wellbeing Profile, 2008)

The Angus Journey

The Angus Journey in Complex Care Management: Step One

•Preliminary studies within general practices in 2006, reviewing complex care pts on basis of Uniquecare criteria

Key Findings from Preliminary Studies

• Patients identified through this process all deemed as complex by professionals involved

• Patients were not high users of unscheduled care

• All patients proactively managed within general practice, with impact of QoF evident

• Recurring themes in those who did have > unscheduled care ( COPD, mental health and/or alcohol issues)

• Issues in entire adult population, not particular to older age groups

• Key issues related to coordination of services between primary and secondary care

Uniquecare Criteria vs SPARRA

• Scottish Patients at Risk of Readmission and Admission identified fewer pts than Uniquecare approach (focussed on >65’s)

• 40% pts on SPARRA list had been identified by initial approach

• 27% pts on SPARRA but not in initial approach had died

• Of remaining 33% pts on SPARRA but not in initial approach, renal issues was a predominant feature. Implications of QoF coding also noted

Uniquecare vs LA Care Management

• Small numbers receiving complex care packages within LA

• 17% pts with complex care packages <65 yrs, 73% >65 years.

• Many had just one long term condition, with an impact on ability to self manage

• Stroke a predominant feature

The Angus Journey: Step 2Early SPARRA

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%

As

a %

of P

ract

ice

Pop

Abbey HC

Academy M

C

Annat Bank Practice

Arbroath MC

Brechin HC

Parkview

Castlegait Surgery

Edzell HC

Friockheim H

C

Kirriemuir H

C

Lour Rd G

p Practice

Monifieth H

C

Ravensw

ood Surgery

Springfield MC

- East

Springfield MC

- West

Townhead Practice

Total Number of Patients at Risk of Admission

0.00.51.01.52.02.53.03.54.0

Pati

en

t N

um

bers

Abbey H

C

Academ

y M

C

Annat B

ank P

ractic

e

Arb

roath

MC

Bre

chin

HC

Park

vie

w

Castle

gait S

urg

ery

Edzell H

C

Frio

ckheim

HC

Kirrie

muir H

C

Lour R

d G

p P

ractic

e

Monifie

th H

C

Ravensw

ood S

urg

ery

Sprin

gfie

ld M

C - E

ast

Sprin

gfie

ld M

C - W

est

Tow

nhead P

ractic

e

Patients with 70-90% Risk of AdmissionOther

Injuries

Ill Defined

Mental Health

Digestive

COPD

Resp

Circulatory

Heart Disease

Cancer

The Angus Journey: Step 3Gold Standards Framework for LTC’s

in General Practice•The Gold Standards Framework (GSF) is a ‘systematic evidence based approach to optimising the care for patients nearing the end of life in the community’.

•The focus of GSF is to improve care in the community by optimising the local primary care team’s provision, so that more patients are enabled to live and die where they choose, and un-needed hospital admissions are avoided.

3 processes of GSF include:

• Identification of patients in need of palliative/supportive care

• Assessment of needs, symptoms, preferences etc

• Care planning and delivery.

5 GSF Goals:• Good symptom control.• Patients enabled to live and die well in

their place of choice.• Better advanced care, planning,

information, less fear, fewer crisis/hospital admissions.

• Well supported and informed carers.• Staff confidence, communication and co-

working.

Aims of GSF Project for LTC’s•To explore the impact introduction of the Gold Standards Framework (GSF) in the management of complex Long Term Conditions Management, within primary care, had on patient outcomes and staff satisfaction

Pilot Details

• Based in Academy Medical Centre, Forfar

• Large teaching practice• Practice population 10990• 81% being under the age of 65 • 19% over the age of 65.• Multi-agency participation• 2008-9

‘Top Ten’: Identification

• Identified through SPARRA and Tayside Predictive Tool

Or• Recommendation of patients by core team

member and approval by others• Any adult eligible for inclusion and the

project did not focus exclusively on any given areas of priority from a disease, multi-disease or age perspective

Project Plan

• Education of staff re aims of complex care management, & GSF

• Core list of ‘top ten’ agreed by core team• Inclusion in supportive care register• Monthly meets aimed to improve the flow of

information, advance care planning and measurement/audit of outcomes

• Shared care planning

Our Top Ten!Patient No

Age Long Term Conditions(List all)

How Identified?Sparra/PEONY/Team/Other

Services at Outset of Projecteg GP, DN

New services or changes to care as a result of pilot

Emergency Care Contacts 6/12 pre-pilot

Emergency Care Contacts 6/12 during pilot

Eg 85 CHDDiabetes

District NurseNot on SPARRA

DNGP

Care management

10 5

1 69 DIABETICHYPERTENSION

PN PN 3 0

2 61 CHDMS

CM CM+DN 0 0 and no GP visits

3 79 COPDCKD

SPARRA PRACTICE 2 2

4 68 COPDCKD

DN ALL DIED DIED DIED

5 74 DIABETICHYPERTENSIONCOPD

DN DN + CM 2 2

6 83 HYPERTENSIONCHDCOPDCKD

DN DN 0 0 and 0 OOH callouts

Patient No

Age

Long Term Conditions(List all)

How Identified?Sparra/PEONY/Team/Other

Services at Outset of Projecteg GP, DN

New services or changes to care as a result of pilot

Emergency Care Contacts 6/12 pre-pilot

Emergency Care Contacts 6/12 during pilot

7 59 DIABETICCHDCKD

DN DN PN 0 0 and 0 OOH callouts

8 82 HYPERTENSIONCHD

CM CM + DN 1 0 and 0 OOH callouts

9 67 HYPERTENSIONMS

CM CM 3 0

10 78 CHD SPARRA CM + PRACTICE

2 0 and 0 OOH callouts

TOTALS 13 4

Q1. In your opinion, has this project improved communication between the professionals involved

in the care of the patients included?

100%

0%0%

YesNo DNA Q2. Has your understanding of the roles

performed by other professionals involved in the project improved as a result of this project?

72%

14%

14%YesNo DNA

Q11. Do you feel that this project has been a success?

100%

0%0%

YesNo DNA

Staff Views on Most Effective Means of Pt Identification

• ‘Case discussion. SPARRA chose patients that were deceased or had very little input from both social work and health’

• ‘I decided to use the SPARRA data as a tool for identifying my patient. This proved ineffective due to its basis on retrospective data and in fact my patient had no admissions or GP contacts during the duration of the pilot despite multiple co-morbidities and numerous preceding issues, which required MDT work.’

• ‘SPARRA search and individual proposal of suitable patients. Some patients we felt who would be suitable for inclusion did not appear on the electronic search’

• ‘Individual/team knowledge’• ‘Best “mechanism” for patient identification was without doubt

the DNs!’

The Angus Journey: Step 4

• Cross reference of SPARRA lists with existing care/case management services, to aid dissemination of information/use of data

• General Practice : Quality & Outcomes Framework +

• COPD Anticipatory Care Project

COPD Anticipatory Care ProjectAll COPD patients registered with Montrose practice with COPD related admission during period of pilot

All COPD patients registered with Montrose practice with COPD identified by SPARRA as being at risk of recurrent admission

Clinical agreement of suitability of any other COPD patient registered with Montrose practice

Agreement of inclusion of patient in anticipatory care project by clinicians with links with Palliative Care DES and advice from other agencies where appropriate.(Maximum caseload to be agreed, approx 15 patients at any given time)

1. Holistic assessment by COPD nurses offered to all patients identified through SPARRA or team, who have not had a COPD assessment by housebound service within last 6 months.

2. In addition to normal care, all COPD related discharges will receive a joint assessment visit by DN and COPD housebound nurse on the next working day after discharge (even where ESD in place).

1Care plans to be developed, with a focus on patient goal setting and self management education, using the BLF COPD Self-Management Plan in all cases, and Palliative Care DES information if appropriate.

2 Anticipatory care planning for all patients, including recording of information in OOH systems.

3 Urgent referral to pulmonary rehabilitation if appropriate.4 Standardised community and COPD housebound nursing documentation to be used.5 Ongoing implementation of care plan, with minimum of 3/12 review.

Criteria Pt1* Pt2 Pt3* Pt4* Pt5*

Smoking status Smoker

Smoker

Smoker

Immunisation status

Assessment of MRC dyspnoea score

3 3 2 2 3

Medication review

Inhaler technique

Education

Self-management BLF booklet

BLF booklet

BLF booklet

BLF booklet

BLF booklet

Co-morbidities

Assessment of psychological co-morbidity

Anticipatory care planning

on Taycare

on Taycare

on Taycare

on Taycare

on Taycare

Others TaxicardRescue medsExercise advice

Referral for anxiety mgtNew devicesReferral to pulmonary rehab

OT referralExercises

Meds changesDevices changesRescue medsCMT referral

Smoking cessation adviceNew devicesMeds changesExercise on referralReferral to pulmonary rehab

Status at end of project

On DN service books prior to project. Care ongoing

Admitted onto DN caseload & COPDHousebound service

Admitted onto DN caseload & COPDHousebound service

Discharged Discharged back to PN

Pt6* Pt7 Pt8* Pt9

Smoking status Smoker

Immunisation Status

Assessment of MRC Dyspnoea Score

4/5 3 5 4

Medication Review

Inhaler Technique

Education

Self Management BLF booklet

BLF booklet

BLF booklet

BLF booklet

Co-morbidities

Assessment of Psychological Co-morbidity

Anticipatory Care Planning

on Taycare

on Taycare

on Taycare

on Taycare

Others Rescue medsContinence assessment

Rescue medsFlu vacOral thrush identified and tx, and oral hygiene taughtCommenced antidepressantsReliant of nebulisersTaught re use of aerochamberPortable O2 arranged for holidays

Meds changedRescue medsInhaler techniqueDental referral

Flu vacReferral to pulmonary rehabilitationRescue medsReferral to pulmonary rehab

Status at End of Project On DN service books prior to project. Care ongoing

Discharged back to PN On DN service books prior to project. Care ongoing

Admitted onto DN caseload & COPDHousebound service

General Observations Regarding SPARRA

•Accuracy of data sources•1/4rly report limiting•? Finding patients too late?•? Disadvantaged by lack of GP data feed?•Variable use of SPARRA data

To effectively implement and evaluate systems for complex care, we need a tool to effectively identify those who we can effectively make a quantitative as well as qualitative impact

Next??•Virtual wards•QoF+•? Enhanced service within general practice