DELIVERING A VALUE-BASED LYMPHOEDEMA SERVICE FOR WALES - DR MELANIE THOMAS NATIONAL CLINICAL LEAD/ ASSOCIATE DIRECTOR LYMPHOEDEMA IN WALES
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
DELIVERING A VALUE-BASED LYMPHOEDEMA SERVICE FOR WALES DR MELANIE THOMAS NATIONAL CLINICAL LEAD/ ASSOCIATE DIRECTOR LYMPHOEDEMA IN WALES
What is Lymphoedema?
4
3
2
1
Think of the wasted
5
amount of NHS cash
spent with No Value
6 7
8
9
QUESTION TIME WHERE YOU WORK DO YOU HAVE A LYMPHOEDEMA SERVICE? 1.YES 2.NO 3.Have no frigging idea
WHICH IS THE ODD ONE OUT?
Dr Andrew Goodall,
Vaughan Gethin Dr Brian Gibbons, Mark Drakeford Boris Johnson,
Countess of Edwina Heart HRH Prince Charles
HRH The Queen Carwyn Jones Wessex
BACKGROUND 40000
National Performance data
6.64 per 1,000
• 2009 WG Strategy published
36759
• 2011 £1 million recurring funds
35000
2 per 1,000
31700
34605 36,187
31408
• Capacity bursting through demand 30000 30167
30701
30100
• Changed skill mix ↑Capacity 25000
26560
• Breaches to see New Patients ↑ 20000 18578
20616
19256
17592
• Gap between capacity & demand ↑
16507
15407
15000 13603
• Consequences of Lymphoedema = 12117
rise in costs 10000 9069
7458 7414 7687
7266
• 2019 Value-Based Lymphoedema 4814
6264 6375
5000 4180
Business Case 3512
• What is valuable to patients and how 0
2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019-20 20/21
do we know?
Referrals Caseload Discharges Total activity
Value-Based Healthcare
Value for Patients
Value = Outcomes
Cost of delivering outcomes
Cost
Quality
££££
Outcomes
MEGAN’S STORY • Chronic lymphoedema • House bound- really? • Immobile- really? • Carers 3 times daily- Why? • Admitted to hospital 6 times in last 12 months with Cellulitis averaging 60 days. ? £££ • Bilateral knee replacements! © Melanie Thomas
MEGAN’S JOURNEY VALUABLE?
• Numerous appointment with • District nurses twice a day
GP for infections and pain • Tissue viability nurse due to
• Referred to consultant surgical wound
dermatologist • Physiotherapy
• Vascular surgeon • Occupational therapy
• Orthopaedics • Dietetics
• Plastic surgery • Chiropody
• Falls Clinic • Social work
Not forgetting numerous hospital admissions for Cellulitis £££
VALUE BASED HEALTHCARE
What did she really want?- How could we have found out?
“I want the pain
sorted in my leg
so I can drive my
car- bit of
independence so I
can go see my
friends”CONSEQUENCES OF MEGAN’S PATHWAY?
• Cellulitis- Cost- Emergency Department/ admission average 11 days /
antibiotics 6 admissions costing £24K
• Wasted resources/ prescriptions- Cost inappropriate garments, bandages,
dressings, diuretics £10K
Average
• Wasted appointments- Cost GPs/ Consultants/ AHP/ £5K
estimate 82K
• Consequences-Falls ambulance/ ED/ X-rays…. £3K
expenditure
• Social Care costs carers 3 x day11K with no value
• Community Nurses daily visits- 352x £82 = 29K
• Quality of life implications
• People cannot work no taxes/ claiming benefits
• 80% had had to take time off work with 8% having to stop work completely
• 50% had had recurrent episodes of cellulitis /50% reported uncontrolled pain. (Moffat et al
2003) CostVALUE BASED PATHWAY
1 x GP Home Visit = £131
• Went to GP for swollen legs and 1 cellulitis admission= £4k
pain- referred to Lymphoedema 10 bandaging visits = £530
Service Dressings/ garments= £1200
• Admitted with 1 x cellulitis 2 x year LO clinic= £100
referred to Lymphoedema Clinic Total= £5,961
So £82K versus £6K
• PROM issued
• Pain relief
• Course of Lymphoedema
Bandaging 10 sessions Healed wounds
• Issued with compression Legs swelling
stockings reduced
Drives her car
• PSSRU=Personal and Social Services Research Unit (Curtis
and Burns, 2018: 119) Pain controlledSO WHAT?
• 2012-2013-Burden of wounds costs
the NHS £5.3 billion (Guest et al., HEALTHCARE
2015). • Care is reactive not proactive.
• 2017-2018 wounds will costs £8-9 • Waiting lists
billion (Bushby, 2017) and
• No Value for Patient
Superficial wounds expected to rise
annually by 12% • Outcomes poor
• Chronic oedema patients also
suffer repeated cellulitis episodes
and account for 2-3% of all hospital
admissions.NORMANS STORY
Consequences of Lymphoedema
NHS PATIENT
Cellulitis Poor Quality of Life
Wounds Massive psychological
Impact on NHS in
issues
Falls Capacity and
Dependency
Wasted Resources Money Unable to Work
&
Variation & Harm Poorly understood
Huge Impactcondition
on
our Patients
Pressure on Unscheduled Obesity
care
Lack of awareness Lack of awarenessWHAT CAN WE DO ABOUT IT?
PROBLEM 1: COMMUNITY
REFERRALS
• Deliver education ‘on the ground’ to enable
effective prompt management of
Lymphoedema
• Raise skills and competence to treat leaking
“wet legs” and superficial wounds quickly
• Reduce waste, harm and
variationOGEP(ON THE GROUND) • December 2021 ( transformation money) 1 band 7 and 1 band 4 • Objective- reduce the risk of secondary complications arising from ineffective, sub-optimal and inappropriate compression therapy • Aim- upskill and increase competencies in compression therapy within Wound Clinics and in the Community Settings • Ultimately Reduce Waste, Harm and Variation and improve efficiencies and effectiveness
ACTIVITY OF OGEP 60% oedema
20% known to Lymphoedema Service
Total Patients seen 309 Number of Patients with
Oedema
Wound clinic patients 195 80%
Overweight At Risk 123
NO DATA =
Community patients 114 Mild Oedema 14
Moderate Oedema 17
(Including DN support)
Severe Oedema 1
Total Activity 1,449 Complex 9
Complex with wound 145
NO PROBLEM
Number of Health Care 74 0 20 40 60 80 100 120 140 160
Professionals worked with What have we done?
Full economic data 134 Increased compression level 36%
collected (70 full reviews) Changed bandages to 16%
compression garment
All Patient Frailty Scores 57%
80
42 51
68
47 42
Commenced Compression 42%
60 39
40
20
15
3 2
Garment
0
Very Fit Well Managing Vulnerable Mildly Frail Moderately Severely Very Terminally Remain the same 6%
Well Frail Frail Severely Ill
FrailOGEP PATIENT PROMS
EQ5D5L Health score today Pre 52/100 Post 67/100
Average Pre and Post PROM Scores
7
6
6
5.1 5.1 5.1
5 4.8
4.4
4.2
3.9
4 3.7 3.7
3.4 3.5
3.2
2.9
3 2.6
2.4 2.3
2 1.8
1
0
Pain Heaviness Homelife Personal Body Walking Anxiety Hobbies Shopping
Care Image Level
Pre Post
*Four of the LYMPROM categories allow patients to choose N/A so these
categories have been excluded from the data below – these are Work, Finances,
Intimacy/Desirability and Holidays.BENEFIT REALISATION Based on 70 patients Pre Post
Number of formal training 24 Community/Practice/ Wound 1,346 1,081
sessions Nurse
Number of professionals 111 GP contacts 67 36
attending training session
Emergency Department 5 6
80 Registered and 28 unregistered
3 student nurses Cellulitis Episodes 23 10
Competencies completed 33 SAFE DELEGATION= REDUCTION IN COSTS
Registered 12 Unregistered 21
30% of patients seen
• Marginal Gains- competent Band 3 (£21) instead of Band 5 (£39)(PSSR)
discharged from
community/ wound
£18 per session x 2 week x 50 patients over 1 year = 93K clinic case load
• Collaborative care to improve outcomes- patients healed off caseload
• Competent and confident workforce consumables Cellulitis Staff time Total
Pre 21,329 57,132 45,992 124,453
• More effective and efficient solution Post 6,831 24,840 37,407 69,078
Saving 14,498 32,292 8,585 55,375PATIENT REPORTED OUTCOME MEASURES LYMPROM©
SITE 2. SBU HB 6/12 DATA
• 95% (1271/1332) had some impact – score ≥ 1
• Average score 53 (range 1-128)
• Average item score 5 (range 0-10)
• Gabe-Walters, M., Thomas, M. Developing the Lymphoedema Patient Reported Outcome Measure (LYMPROM©)
in adult Lymphoedema Services in Wales: examining feasibility, acceptability and internal validity. British Journal
of Nursing
Average LYMPROM score by age
• Problems: 70
63
57 57 59
• Shopping for clothes / shoes 5.75 60
54 55
46 46
• Body image 5.55
50
40
35
• Intimacy / desirability 5.34 30
• Heaviness 5.30 20
• Walk 5.28 10
• Home life 5.17 0
18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ (blank)So What?
PALLIATIVE ROUTINE
REFERRAL – REFERRAL –
MUST BE SEEN MUST BE SEEN
WITHIN 2 WEEKS WITHIN 12 WEEKS
PROM
BASED
DRIVEN
SERVICENumber of Score Score Score Score
questions
answered
13 Less than or equal to 13 14 - 77 78 - 103 More than or equal to 104
12 Less than or equal to 12 13 - 71 72 -95 More than or equal to 96
11 Less than or equal to 11 12 - 65 66 – 87 More than or equal to 88
10 Less than or equal to 10 11 - 59 60 – 79 More than or equal to 80
9 Less than or equal to 9 10 - 53 54 – 71 More than or equal to 72
8 Less than or equal to 8 9 - 47 48 – 63 More than or equal to 64
7 Less than or equal to 7 8 - 41 42 – 55 More than or equal to 56
6 Less than or equal to 6 7 - 35 36 – 47 More than or equal to 48
5 Less than or equal to 5 6 - 29 30 – 39 More than or equal to 40
4 Less than or equal to 4 5 - 23 24 – 31 More than or equal to 32
3 Less than or equal to 3 4 - 17 18 – 23 More than or equal to 24
2 Less than or equal to 2 3 - 11 12 – 15 More than or equal to 16
1 Less than or equal to 1 2-5 6-7 More than or equal to 8
Contact within 12 weeks See within 12 weeks See within 4 See within 2 weeks
by telephone to Options- phone, Virtual weeks Options- phone, Virtual
determine need for or Face to Face Options- or Face to Face
appointment and discuss phone, Virtual
discharge or Face to
Face
• Follow Up appointment-Issued with LYMPROM before appointment via
DrDr No need for face-2- face- attend anywhere or a phone call and
Discharge if LYMPROM low numbersCOMPRESSION GARMENTS REDUCING WASTE
HARM AND VARIATION
• 1000’s variations
• Numerous suppliers
No set prices!
Different discounts!
No standardisation!
Process all wrong
and lots of cockup
factors!HAS TO BE A MORE PRUDENT WAY?
• Met with all clinicians/ NHS
Shared Services
• Met with all manufactures
• SMTL
• Developed A National Contract
For Compression Garments
• Standardised Process
Best Outcome
Best Price
StandardisationNATIONAL FORMULARY AND NHS WALES CONTRACT FOR
COMPRESSION GARMENTS
• 2014-2018 Contract commenced savings around 135K
• More than money- do no harm
• Simplified the process...
• However, can we do better? As lots of garments issued
via prescriptions?
• Welcome to Project BPROJECT B
Patient needs
PRESCRIPTION ROUTE Garment PROJECT B
• Garment given on
• No price guarantee Prescription Non-medical Garment fitted as in
stock Procured assessment so
request to GP prescriber issued
• Involves superfluous prescription and within immediate-
•
informs GP Lymphoedema
processes- GP/ Community Patient attends services, and Streamline process
Pharmacy/ Prescription GP to collect informs GP supporting
prescription
Clerks sustainability
• No benefit to patient in Patient takes
prescription to
Immediate • No travel for patient
process pharmacy as garment issued
• Travel for the patient taking on appointment
Compression
prescription and collection- garment is • Improved
cost to patients ordered
concordance
• Delays to patient accessing Patient returns • No waste, harm or
treatment to pharmacy to
collect garment
variation- cock up
• Waste, harm & variation
factor diminished
•
Patient returns to the
• Increase Cost for NHS Lymphoedema service to 20-25% cheaper
Wales
have compression garment
fitted • Best Price as NHS
Contract
6-8 weeksProject B- what do we need to prove?
Criteria Metrics
Care Outcomes Numbers of patients receiving the right garments with no errors
Quality of Care- Before Numbers of patients receiving the right garments on assessment
and After Project B % of issues or errors
User experience Time waiting for garments
Accessibility/ quality of Travel time and costs of accessing garments
interactions/ patients Availability of garments in stock
choice % of patients receiving garments if New or FU
Safety / Quality % of harm encountered by patients in wrong garments being issued
Avoidance of harm % adherence to NHS Compression Garment Contract
Safe environment Activity levels in Health Boards
Adequate resources Garment Budgets in Health Boards
Revenue Costs Budgets for Garments
% changes in annual spendsProject
PROJECT B B- Evaluation- Swansea University
METHODS Only 9% (461) required appointment
Audit form completed by therapists for fitting compared to 80% (4,314)
each time issued garments
Time for orders- (39%) waited over
RESULTS
11 days. Main reason being lack of
5,392 patients entered into evaluation administration (why we need a band
from SBUHB (64%) and CVUHB (36%)
3!)
18% New Patients 82% Follow Up
Non-contract orders took on average
92% contract; 8% non-contract
12 days compared to contract on
52% fitted on the day; 41% ordered;
average 7 days
7% made to measure
71% New patients fitted on the day 100% of patient received the right
product!Benefit Prescribing Project B
effectiveness (service quality Lots of harm, waste and variation. Patient No waste, harm variation
including patient outcome, complaints No complaints
experience and satisfaction) Loss of compliance Patients receive garment at the best
Waits of treatment time
supporting strategic goals Lots of travel to access garments- GP, Less travel for patients, No CarParking,
(including social, environmental Pharmacy, Hospital, Pharmacy- time off excess petrol, time off work
and wider economic aims) work,
risk mitigation and avoidance Lots of processes so increase of errors Decrease waste, harm and variation
Workforce Tasks with no value Skilled workforce
5,392 patients Prescribing route Project B
Garment cost £55.60 £40.40
Garment plus staff costs £78.90 £41.50
Overall costs Procuring route £424,716
Overall costs Prescribing route £808,244
Overall Difference in costs -£383,528CASE STUDY
• Not considered 2 garments in a box!
• 18-19 £16.97 and 19-20 was £17.11!!
• 20-21 total cost estimated at £214K instead of 300KLYMPHATIC VENOUS ANASTAMOSIS
• Welsh Government funding September 2015 Innovation/ Technology funding
• Initially for 2 years now permanent
• Only happened in Wales!
• 153 LVA surgeries on the NHS
•• 153 LVA surgery (10 waiting) • 648 episodes of cellulitis reduced to 28 (96% improvement) • 73 hospital admissions due to cellulitis reduced to 6 (92% improvement) • 2,103 days off work due to cellulitis reduced to 53 (98% improvement) • 31 patients no longer require compression garments and 31 patients are being weaned off compression garments (59% reduction in the need for compression therapy)
Physical symptoms
5
pain heaviness
4
3
2
1
0
Pre 3 months 12 months 24 monthsNATIONAL LYMPHOEDEMA CELLULITIS
IMPROVEMENT PROGRAMME IN NHS WALES
VALUE- BASED BUSINESS CASE 3 X 8A POSTS FUNDED BY WELSH GOVERNMENT
Consultant Length Bed
Cellulitis Episodes Admissions Emergency of Stay Days
2019-20 7,509 4,790 4,617 10.8 37,194
2018-19 7,564 4,838 4,636 10.7 36,985
2017-18 6,511 4,225 4,053 11.5 32,324
2016-17 7,020 4,554 4,353 11.2 39,001
2015-16 6,805 4,343 4,096 10.6 37,082
2014-15 6,174 4,035 3,782 9.1 34,642
2013-14 6,002 3,864 3,625 10.5 34,844
2012-13 5,779 3,685 3,477 11 33,206
2011-12 5,525 3,491 3,304 12.5 33,170BACKGROUND
Primary Objective – To offer all people given a diagnosis of cellulitis in secondary
care an evidenced based intervention to reduce their risk of recurrence and
pressure on unscheduled care
Secondary Objective - Develop cellulitis patient reported outcome measures
AIMS
Increase patient awareness in identifying and managing Cellulitis;
Improve patient understanding of their risk factors for Cellulitis;
Reduce incidence of recurring Cellulitis episodes through assessment,
education and and treatment of identified risk factors
Increase Health Care Professional awareness in identifying and managing
Cellulitis
Improve Healthcare professionals understanding of risk factors for CellulitisACTIVITY OF NLCIP (DATA UP TO 27/05/21)
Patients Contacted Total = 4,359
Number contacted Response Rate
Princess of Wales 957 45%
Prince Philip 292 49%
UHW 1,806 38%
Neath Port Talbot / 702 61%
Singleton
Neville Hall 601 ongoing
All 3,757 patients contacted have received a
“Reducing the Risk of Cellulitis” leafletNormality= Lost days
CELLULITIS OCCURRENCE (721 PATIENTS) from work, personal life
Over 18 months Av Over 18 months length of stay Normality lost for patients
Average Episodes 2.4 Average 2.6 3.2
Max 32 Max 81 90
Total 1,752 Total LOS 8,613 10,272
Location of cellulitis Upper Limb Lower Limb Trunk Head / Neck NA
Total 117 529 643 27 12
% 16% 73% 9% 4 2%
Age No %
66% 0 to 10
11 to 20
0
3
0%
1%
over 21 to 30
31 to 40
12
39
2%
5%
55%
(396) 61 41 to 50 64 9%
51 to 60 124 17%
61 to 70 178 25%
45%
71 to 80 164 23%
(325)
81 to 90 117 16%
91 - 100 20 3%CELLULITIS CAUSE & RISK FACTORS
Bite Post Op Bite
(insect) Scratch infection Unknown Canula (other) Wound Fungal Other Trauma
Number 49 28 62 206 17 16 257 22 77 16
% 7% 4% 8% 28% 2% 2% 34% 3% 10% 2%
Risk Factor to Cellulitis
450 1.2
381
400 346 337 1
350 300
300 0.8
250 215
0.6
200
150 0.4
100 68
0.2
50
0 0
Lymphoedema Obesity Diabetes wounds cardiac Blood pressure
30% 27%
25% Frailty Score (n = 721)
20% 17%
Obesity Yes No
15%
14%
16%
10%
41% >4 381 338
10% 7% 8%
5%
1% 0% 53% 47%
0%
1 2 3 4 5 6 7 8 9RISK FACTOR- LYMPHOEDEMA
48% (346/721) of patients seen had Lymphoedema.
57% (196/346) not known to Lymphoedema Services
Lymphoedema Severity Met Patient on Requested
380
400
350
prophylaxis Prophylactic prophylactic
300 Antibiotics Antibiotics Antibiotics via GP
250
200 criteria
150 120
100 80
48 60
50
33
0
At risk Mild Moderate Severe Complex Complex
85 41 (-44) 42
wound
Weight
Treatment Advice Skin care Exercise Management Compression
Number 720 720 696 659 143
% 100% 100% 97% 91% 20%PATIENT REPORTED OUTCOME MEASURES CELLUPROM©
7
Significant changes from pre to post scores pEDUCATION UPDATE
• New accredited Agored unit November 2020 – Via Teams
Promoting skin care for people PH54CY025 Additional Education Sessions
with lymphoedema to reduce the Provided
risk of cellulitis (18) Formal sessions 5
External attendees 13 (72%)
Number of attendees 80
Internal attendees 5 (28%)
Completed workbooks credits 4 (22%) Includes Therapies
achieved to date
(OT/Physio/SLT), Acute Clinical
Teams (GPs, Consultants,
Video Film and E-Learning currently
Advances Practitioners, Nurses,
under development these will be HCSW
available to the public and integrated
into the Agored unit when completeBENEFIT REALISATION-FINANCIAL 721 COMPLETED PROGRAMME Pre intervention Projected (50%) Post intervention 721 patients Number Cost £ Number Cost £ Number Cost £ Numbers of cellulitis 1,752 876 17 Numbers of GP (£36) 463 £16,668 232 £8,352 16 £576 Number of Emergency Department contacts (£120) 1,550 £186,000 775 £93,000 1 £120 Numbers of nights occupied in hospital for cellulitis (£217) 7,884 £1,710,828 3,942 £855,414 10 £2,170 Antibiotics costs 8 days IV (£150) 1,752 £262,800 876 £131,400 1 £150 7 days oral average (£5) 1,752 £8,760 876 £4,380 17 £85 COSTS £ 2,185,056 £1,092,546 £3,101
WHAT ABOUT PRIMARY CARE AND CELLULITIS?
• SAIL database 1999-2019- (20 years)
• 400,200 people (20 Years)
• 620,000 contacts (20 Years)
• In 2019, 22,000 contacts for GPs for
Cellulitis
• In 1999, 7,000 contacts…. Welsh Index Multiple Deprivation
• Means we need to educate primary WIMD quintile N
care! 1. Most Deprived
2.
70,690
56,535
3. 56,801
4. 48,190
5. Least Deprived 52,487THANK YOU
DIOLCH YN FAWR
QUESTION 2
ARE YOU GOING TO CONTACT/
FIND OUT IF YOU HAVE A
LYMPHOEDEMA SERVICE
1.YES
Melanie.J.Thomas@wales.nhs.uk 2.NO
A @lymphwalesYou can also read
