Long term conditions in general practice. Part 2: Patient management
In the second of two articles on the management of long term conditions in a general practice setting, we will discuss the assessment and review of patients and how to support self-management
Long term conditions are health problems that cannot be cured, such as diabetes, heart disease or respiratory disease. Usually the symptoms and progression of the condition can be controlled through medical management and lifestyle interventions. Long term conditions are often managed in primary care; management includes health education, support to achieve self-management, symptom and deterioration recognition and medical management.
LONG TERM CONDITIONS REVIEW
There are many factors that influence the frequency of review for patients with long term conditions. They will need to have an annual review of their condition but those who are newly diagnosed, are having their medications optimised and those with uncontrolled symptoms or co-morbidity will need more frequent reviews.
The review consists of a clinical assessment, a review of symptoms, a lifestyle assessment, a medication review and monitoring for risk of, or signs of, complications. Following this a management plan will be developed between the patient and the clinician, which will include health education, self-management skills and medication titration.
The needs of patients with long term conditions who are housebound need to be considered. It is important to work with other members of the multidisciplinary team who may be already involved in the patient’s care to ensure they are having optimal care of their long term condition. For example, a community nurse providing wound care to a housebound patient will have a vested interest in the management of the patient’s diabetes in order to promote the best wound healing conditions and could provide relevant health education and self-management advice to the patient.
PATIENT ASSESSMENT
The clinical assessment will include all observations that are relevant to the individual patient’s specific long term condition(s) which may include recording blood pressure, pulse, temperature, body mass index, waist measurement, peak flow or performing chest auscultation or a foot check. It will also include a review of any blood tests or investigations that have been carried out prior to the appointment.
A review of symptom control gives an indication of how well the long term condition is being managed. It is important that patients report what symptoms trouble them and what exacerbates them as well as what impact they are having on their daily life. A tool such as the Medical Research Council breathlessness scale1 or a visual pain scale can be useful to quantify symptoms.
An assessment of the patient’s lifestyle highlights any behaviour that might be contributing to the patient’s current condition and symptoms or that may put them at risk of future complications. Using appropriate consultation skills, allowing the patient to tell their story and using open questions, the general practice nurse (GPN) needs to elicit accurate and honest information from the patient regarding their activity levels, smoking status, diet and alcohol intake.
It is also important to assess the mental health of the patient as people with long term conditions are two to three times more likely to have mental health problems such as anxiety and depression.2 Mental health problems contribute both to poorer clinical outcomes as well as increasing the likelihood of risky lifestyle behaviour. Using the two question depression screening tool (see Box 1) can help identify possible depression.3 If detected in a timely manner mental health problems can be managed with interventions such as exercise, cognitive behaviour therapy or medication which will improve the outcomes for the patient.
A review of the patient’s current medication should include what medication the patient has been prescribed as well as what over the counter or herbal medications the patient is taking as this may impact on the patient’s condition. For example, some patients with heart failure can get increased symptoms, such as breathlessness, after taking over the counter non-steroidal anti-inflammatory medication for a musculoskeletal condition. It is also useful to ascertain the patient’s concordance with their medication regimen. It is possible to find out from the patient record how often the medication has been prescribed but this does not mean it has been dispensed or taken by the patient. Fifty percent of medication prescribed for long term conditions is not taken or not taken as it was prescribed.4 A medication review should also clarify if the current regimen is controlling the symptoms and not causing undue side effects.
It is important to monitor the patient for signs of complications such as end organ damage in patients with hypertension or neuropathy in patients with diabetes. It is also an opportunity to ensure that the patient has undergone screening or treatment provided by other members of the multidisciplinary team such as cardiac rehabilitation or diabetic retinopathy screening. It may also be necessary to undertake a cardiovascular risk assessment in some patients, particularly those with hypertension.
DEVELOPING A MANAGEMENT PLAN
Following a thorough assessment, the GPN and patient will develop an agreed plan of care. This plan should be patient-centred and evidence-based and use a collaborative, partnership approach with the patient at the centre of the process. The plan will include optimising the medical management to ensure the patient is on the best medication regimen to prevent deterioration of their condition and alleviate symptoms, as well as a comprehensive package of health education. The relevant NICE guidelines provide detailed, evidence based guidance for managing each long term condition. (See new Guidelines in a Nutshell series at practicenurse.co.uk)
Health education should address all the risks identified in the lifestyle assessment and will include smoking cessation support, dietary and alcohol intake advice and physical activity advice. Modification of lifestyle factors can be very difficult for patients and clinicians must be aware that changing behaviour is a complex process influenced by psychological, social and environmental factors. It is important to assess the patient’s readiness to change and work with the patient to set realistic and achievable goals. The GPN must resist the temptation to solve the patient’s problems but guide them to make their own decision. Motivational interviewing techniques are useful in facilitating change behaviour. The GPN should attempt to evoke ‘change talk’ where the patient indicates they are motivated to change their behaviour.5
A behaviour modification plan must be agreed between the GPN and the patient and include specific and realistic goals that can be easily measured, for example walking for 30 minutes three times a week rather than planning to run a marathon in six months’ time. It is better to make incremental changes rather than large changes as this promotes successful experiences that can be used to encourage additional lifestyle modification if needed.
SUPPORTED SELF-MANAGEMENT
On average, people living with long term conditions spend three to four hours a year with a health professional leaving a significant amount of time where they are self-managing their long term condition. Patients supported to self-care are more likely to feel better and in control of their health and less likely to be admitted to hospital or suffer from depression.4 Over 90% of people with long term conditions are keen to be involved in managing their condition and 75% state that their confidence to do so would be increased if they had the right support.6
In order to be able to self-manage effectively patients need the support of a clinician and the appropriate knowledge and skills to manage their condition safely. This involves an understanding of the long term condition itself, risk factor reduction, how to detect deterioration and how they can manage it as well as when and how to seek medical advice. Examples include patients with asthma knowing how to avoid or mitigate their individual asthma triggers or patients with chronic obstructive pulmonary disease recognising the signs of a chest infection or exacerbation and knowing when to take their standby antibiotics and steroids.
Some patients need 'permission' to manage their condition autonomously as they have been used to following the direction of the health professional. For example patients with heart failure can be taught to titrate their diuretic medication according to their symptoms and daily weight – which not only means they have fewer symptoms but also avoids unnecessary hospitalisation due to exacerbation of their symptoms.
Specific advice also needs to be given to patients on how to manage their condition when they are out of their usual regime, for example on holiday or during Ramadan. They also need to know how to manage their condition when they are unwell with something unrelated to their long term condition such as a viral illness.
In order to encourage patients to self-manage it can be useful to send them their test results before their review so they can assimilate these and start to come up with a plan which can be discussed and agreed during the consultation. It is useful for patients to have a written care plan so that they have a record and a reminder of what was agreed. Templates to support this are available, such as the Asthma Action Plan.7
Patients should be provided with information about suitable resources to support what is discussed and agreed during the review. Organisations such as the British Heart Foundation, Diabetes UK, the British Lung Foundation and Asthma UK all provide up to date, evidence based resources for patients either in print or on their websites. Some patients may find apps that they can download more useful. This can be particularly helpful to support behaviour change as they provide motivational support as well as useful information and the facility to track progress towards the goal. The NHS Choices webpage has details of health and fitness tracker apps which are free to use.8
When facilitating supported self-management it is important to take into account any memory problems, communication issues, and/or cultural factors that may influence an individual’s ability to self-manage. Family members or carers should be involved in the process to support the individual to self-care wherever possible – if the patient consents to their involvement.
It is important to provide a safety net for self-management so that patients are aware of situations when they do need to seek urgent medical advice such as postural nocturnal dyspnoea in heart failure patients, chest pain at rest or unexplained hypo or hyperglycaemic episodes.
REFERRAL TO OTHER MEMBERS OF THE MULTIDISCIPLINARY TEAM
It is vital that GPNs work within their competence when managing long term conditions to ensure that the patient receives appropriate and safe care. A study by Medical Protection revealed that most claims against nurses in general practice involved failure to refer the patient onwards to either a GP or another member of the multidisciplinary team.9
GPNs should discuss with the GP or refer to another agency anything that is outside their sphere of competence such as any uncontrolled symptoms, adverse findings or side effects from medication. If the GPN is not an independent prescriber the GP will also have to make any adjustments to the patient’s medication.
Some patients will require specialist dietary advice from a dietitian, e.g. those with diabetes, and some may need to be referred for counselling or cognitive behavioural therapy. The GPN must be familiar with what services are available locally to support patients with long term conditions, such as cardiac or pulmonary rehabilitation, weight management programmes, health walks or drug and alcohol services as well as the structured disease specific programmes like DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed).
AUDIT
It is important to monitor the effectiveness of long term condition management in primary care. The Quality Outcomes Framework (QOF) aims to improve the quality of health outcomes for patients and there are QOF targets for the most common long term conditions. The practice can secure payment based on how well they achieve these targets. However, QOF measures are quite general and do not always quantify how effectively the patients are being treated.
It may be useful to audit if patients are on maximum tolerated, evidence based doses of medication or are being treated to target levels. Patient satisfaction surveys are also useful. Areas to audit could include asking patients if they feel more able to self-manage their condition, if the appointments are provided at a convenient time or if the patient feels able to access the support they need.
CONCLUSION
Effective management and proactive supported self-management can improve the outcomes for patients living with long term conditions. GPNs need to ensure that patients with long term conditions are provided with the appropriately evidence based care. This care includes medical management, health education, symptom and deterioration recognition and support to achieve self-management. Patients with more than one long term condition should have an integrated review rather than a disease specific one, wherever possible, as this provides a more comprehensive disease review and enables resources to be used more effectively.
REFERENCES
1. Medical Research Council. Dyspnoea scale/MRC breathlessness scale https://www.mrc.ac.uk/research/facilities-and-resources-for-researchers/mrc-scales/mrc-dyspnoea-scale-mrc-breathlessness-scale/
2. Naylor C, Parsonage M, McDaid D et al. Long-term conditions and mental health: The cost of co-morbidities. The Kings Fund, 2012. https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
3. NICE Clinical Guideline 91. Depression in adults with a chronic physical health problem: recognition and management, 2009. https://www.nice.org.uk/guidance/cg91
4. Mathers N, Roberts S, Hodkinson I et al. Care Planning: Improving the Lives of People with Long Term Conditions. RCGP Clinical Innovation and Research Centre, 2011
5. Bussell G. Motivational interviewing to help patients achieve dietary and lifestyle changes. Journal of General Practice Nursing 2016; 2(6): 48-52
6. Department of Health. Public Attitudes to Self-Care Baseline Survey. 2005
7. Asthma UK. Your asthma action plan. https://www.asthma.org.uk/advice/manage-your-asthma/action-plan/
8. NHS Choices. Health and fitness trackers. http://www.nhs.uk/conditions/nhs-health-check/pages/tools-and-technology-that-can-help.aspx
9. Taylor K. Rising Nurse Claims. Medical Protection, Practice Matters 2013;1(1):12-13
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