“The essence of our approach to managed care”

Surrey and Sussex Transforming Chronic Care Programme

September 17 2004

Patients at all levels of the pyramid need some level of assistance to help them to achieve the best possible outcomes

SelfManagement

Level 170-80% of a

CDM pop

Level 2

High riskpatients

CareManagement

Level 3

Highlycomplexpatients

CaseMgt

• The majority of patients do not care for themselves effectively

• The key to an effective systematic approach is to support patients down the pyramid rather than allow them to drift up to highest levels

• Intensive case management is not cost effective beyond the highly complex

Self care Assisted (‘managed’) care

Serum works with PCTs to deliver a fully integrated local care management programme

• Proactive telephone follow up Disease specific risk prevention and self-

management education (Currently asthma, COPD, Diabetes and CHD)

Inbound telephone facility

• GP practice/clinician support Patient referral and coordination

Practice nurse support

• Local integration into care pathways• Detailed reporting and measurement• Project management and delivery

Proactive telephone support is both clinically and cost-effective at keeping patients well and out of hospital

Asthma example - 1 year national case study

• Utilization outcomes Estimated 64% reduction in unplanned asthma admissions

Reduction in emergency primary care visits and use of additional resources

• Quality of life outcomes 86% of patients feel that they have a better understanding of their

asthma

Extensive patient feedback on improved motivation, quality of life and functional ability

"How would you say things are with your asthma at the moment?"

19% 26% 32%

23%25%

39%

46%40%

22%10% 8% 7%2% 1% 0%

0%

20%

40%

60%

80%

100%

1 2 3Call number

% o

f p

ati

ets

Very bad

Bad

OK

Good

Very good

• Clinical outcomes 69% improvement in patients self reported asthma status

40% reduction in reliever medication use

39% improvement in self reported preventer medication compliance

GP - Blackwater Valley and Hart PCT: "Very positive feedback. The advice is first class and on one occasion prompt intervention prevented an admission. “

The additional telephone care improves the patient experience

Patients respond better when given…

• Education on complex conditions and medication • Support at a time and place that suits their needs.• Confidential advice from a qualified nurse• Time to respond to their questions and concerns.• Additional support outside of their GP practice• Follow up to see if they have managed to do what was agreed

Male, 66 - "'It's been a very, very good service. My understanding of asthma and the treatment that I'm on has improved by 100%, since you started making the calls'"

We work to a structured process which manages a programme from initiation to delivery

• Step 1. Nominated PCT leads• Step 2. Agreed support

variables Patient population Recruitment PCT/GP practice integration

and engagement Reporting and measurement

• Step 3. PEC/CDM group/Board sign off

• Step 4. Project plan and Serum delivery

Typical steps from contact to delivery

Our goal is to help you and your patients to achieve the best possible outcomes

• Reduce the burden on secondary care • Help patients to better care for

themselves • Achieve a direct financial return on

investment• Improve the quality of care delivered to

your patients• Improve patients functional status and

quality of life • Ensure best use of medicines and

reduce medicines wastage

About SerumBenefits of a telephone care management programme

• Serum is a leading independent UK provider of healthcare support and information

• The calling protocols were developed by the Serum Intervention Committee whose membership includes Professor Mike Pringle, Professor Stephen Chapman and Professor Rob Horne.  

• The operation runs from custom built decision support software, SCCM (the Serum Call Centre Manager), which is based on US decision support tools.

• The service is delivered to a detailed process of Clinical Governance, in which all calls are recorded, risks reviewed monthly and calling processes managed to an agreed service level agreement.

Perry Blacher

Serum

100 Union St

London SE1 ONL

Tel: 020 7261 9256

Perry@serumgroup.com