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Regional Innovation Fund 2010/11 Project: LTC 20030

Empowering patients to adopt personalised care planning

Nottinghamshire Community Health Services 

 

Evidence which supports staff giving self-management plans to patients with Long Term Conditions states that this alone will not really make a difference to patient experiences and outcomes. So an additional mechanism is needed that helps each patient to change their behaviour.
This project facilitates the development of evidence-based skills in health teams through a programme of training as a mechanism to motivate this change. 
Emergency admissions could be reduced by a quarter if successful, set against a rising trend currently in the East Midlands.
 
Long Term Conditions (COPD, Diabetes, Heart failure) account for the majority of acute medical admissions, readmissions and a large number of primary and community care contacts.
In the community, most patients with these conditions do not receive self-management plans. The concern is that when/if they do, the plans will be given out by a healthcare professional who has not been trained to communicate the plan in a way that promotes or encourages patients to change their behaviour to self manage their condition.  The result is poor compliance by patients to self-manage and continued over-dependency on NHS resources.  In short – the provision of self care plans on their own will not lead to widespread improvements in health, a fall in unnecessary hospital admissions and readmissions and reduced NHS resource utilisation.
 
Whilst self-management by patients with one or more Long Term Condition is increasingly encouraged, we know that simply giving advice to patients, including giving written plans, does not lead to the appropriate and required behavioural changes intended.
The innovation here is to facilitate a programme of training for nurses and doctors to develop and use motivational, evidence-based interview techniques. 
When used alongside self-care plans, these skills will help motivate individual patients to change their behaviour and self-manage their condition, improving their quality of life and reducing hospital admissions and readmissions.

 

  • Increased empowerment and independence through greater understanding.
  • Control and ownership of their long term condition.  
  • Reduction in unnecessary hospital admissions
   
  • Improved staff skills and confidence
  • Increased staff satisfaction
  • Released pressure on hospital beds, especially during the winter.
  • Reduced hospital admissions
  • Reduced hospital readmissions
  • Reduced calls on emergency services and OOHs
  • Reduced GP appointments
  • Reduction in Community Nursing workload
  • Reduced medication and treatment failures

 

This project will deliver 20% cash releasing and additional non-cash releasing productivity gains per annum.
At a cost of £2,500 per admission, this equates to a £500,000 saving per 1000 admissions across the region, plus costs associated with emergency transport call-out.
As evident in the LTC in the East Midlands Report, (21 Jan 2008), COPD is a particular problem in the East Midlands and accounts for the largest proportion of Ambulatory Care Sensitive (ACS) condition emergency admissions.  Data from the report states of all COPD admissions, (n=8568), 3618 were Very High Intensity Users, (VHIU) admissions with cost of approximately £7.1m per annum in bed days.   A 20% saving therefore amount to £1.4m.
Additional non-cash releasing savings will arise through reduced GP, OOHs and community care contacts, thus releasing capacity alongside increased capability within the workforce.
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Contact the Innovator

Mike Ward, Sherwood Forest Hospitals NHS Foundation Trust

Mike.ward@sfh-tr.nhs.uk

Pip Dean,Nottinghamshire Community Health Services

pip.dean@nottscommunityhealth.nhs.uk

 

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Documents to Download

See the project featured in the East Midlands Regional Innovation Fund Projects Brochure on Page 50

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East Midlands EXPO Poster