In the UK, 17.5 million people are living with complex care needs (Nicol, 2011). Eighty per cent of primary care consultations and two thirds of hospital admissions are related to long term conditions (LTC) (NHS Institution for innovation and improvement, 2006). This essay will discuss the complex care needs of an individual based upon a learning experience within a community setting. The Nursing and Midwifery Council (NMC – 2008) code of conduct states that people deserve the right to confidentiality, therefore all names have been changed.
Ernie is an elderly gentleman who suffers from diabetes and hypertension. Ernie’s diabetes is poorly managed due to his diet and he also drinks alcohol excessively. He has suffered several hospitalisations recently. He sees the district nurse three times a week to dress his foot ulcer. This has been going on for many years and the ulcer is showing no signs of improvement. He has had his right foot and the toes on his left foot amputated previously due to ulcers, therefore he uses a wheelchair. Ernie lives at home with his wife Doris who is very elderly. She helps to care for Ernie but cannot manage alone therefore carers come in to help twice a day. The district nurses have expressed concerns to the carers about the malodour of their home and their physical appearance as they appear very unkempt. Ernie has expressed that he does not wish to go into a home.
Ernie deals with various members of the multi- disciplinary team (MDT) on a weekly basis. This can be unnerving and frustrating. Ernie often found himself repeating information about his complex needs to various different healthcare professionals. There were several occasions where appointments were confused as people had not liaised with one another. He waited for hospital transport on one occasion which did not arrive. His experience could have been transformed had there been regular briefing and debriefings between professionals to facilitate the two-way exchange of information (Barker, 2013).
The impact of living with multiple health needs can vary greatly for each individual. The initial diagnosis of an LTC is usually seen as bad news which would suggest some form of loss to the individual. The physical impact of Ernie’s LTC has impacted upon his ability to carry out the activities of daily living as proposed by Roper et al (2000). The psychological impact of living with complex needs can also have a negative impact on health. Haddad (2006) claims those living with a LTC are much more likely to develop depression. Nicholson et al (2006) also claim that those who develop depression are then predisposed to other complications, such as heart failure.
In order to maintain an optimal level of health, Ernie would benefit from integrated care to support him. The Kings Fund (2011) states that integration can happen between primary and secondary care or between different disciplines, such as health and social care. This can be achieved through merging services or by networking. Integrated care as a concept would focus on Ernie’s needs altogether rather than a service provided individually. The aims of integrated care are to improve efficiency, clinical outcomes, patient satisfaction and to reduce cost (Mirella and Minkman, 2012). Integrated care could benefit Ernie as the structure is designed to fit around the needs of the patient rather than the service providers. The biggest challenge to be faced in implementing this is changing the mindset of the services and changing policy (Diabetes UK, 2014). The diabetes centre in Bolton has integrated its services and reported in 2005/6 the lowest number of hospitalisations for diabetic patients in the Greater Manchester Area (The Kings Fund, No date).
Integrated care for diabetics should range from screening and prevention right through to hospitalisations and end of life care. The NHS mandate (2013) requires healthcare professionals to provide better support or those living with an LTC. To support this, Ernie may be a good candidate for telemonitoring – the use of technology to support his health (Barrett, 2012). This could include consultations, support over the phone and measuring his own health at home using equipment. Telemonitoring is becoming increasingly popular after NHS England (2014) plans to develop technology enabled care services. It is intended to reassure patients and their carer’s and improves clinical outcomes. Barrett (2012) states that there has been a high incidence of patient satisfaction and cites research that claims diabetic patients have fewer hospital admissions and better glycaemic control. The system will face challenges though, as the patient may be non compliant or struggle to adapt. Nurses will need to deal with change using this approach as it removes some of the hands-on care they are accustomed to. They may also be required to develop other skills such as clinical triage.
Integrated care pathways (ICP) outline a plan of anticipated care for a specific set of patients; an example of this is the Liverpool care pathway for the dying patient (Neuberger et al, 2013). It forms all or part of the documentation record and it is multi-disciplinary based and written to accommodate all areas of the patient’s care. This provides a single point of communication which can increase the coordination of care. Diabetes UK (2014) outlines the diabetes care pathway for which local services will have protocols for correct referrals and what services are provided. A limitation of ICPs are that not all individuals respond the same throughout the pathway, therefore healthcare professionals need to use their clinical judgement and deviate off the pathway wherever appropriate (Nicol, 2011). As a nurse it may be beneficial to apply the nursing process as proposed by Yura and Walsh (1973) in order to tackle variances encountered – enabling the patient to return to the pathway as soon as possible.
Theoretical frameworks can support the management of LTCs. The Kaiser Permanente and Evercare are two examples of this. The latter focuses more on those at high risk of hospitalisation whilst the Kaiser Permanente focuses on integrating the care of people at all stages of their illness (NHS Institution for Innovation and Improvement, 2006). The Kaiser Permanente approach is underpinned by health promotion for the population. In the UK, the NHS and Social Care Model (Department of Health, (DH) 2005) reflects the Kaiser Permanente and forms a pyramid structure whereby patients are categorised on three levels. Ernie may move from one level to another. Level one is supported self care, level two is high risk care and level three is highly complex care needing case management.
The Kings Fund (2004) defines case management as coordination, managing, planning and reviewing the care of an individual, usually undertaken by a community matron, however, other professionals such as social workers are ideal candidates. Case management should be underpinned by assessment, care planning, implementation and reviewing. Offredy et al (2009) outlines that some benefits to case management include less chance of duplicated care or missed care and also an increased level of trust between the healthcare professional and the service user. It outlines that the barriers to effective case management can include difficulty for the community matron to shift from the traditional reactive care to a proactive approach. Although there is positive evidence for case management, this can be inconsistent.
Effective case management requires collaboration of professionals. Goodman and Clemow (2010) argues that if professionals do not collaborate effectively – or even understand fully the roles of other professionals, then patients’ needs are less likely to be met. A barrier inter-professional working faces is the segregated education healthcare professionals receive. This can create discipline specific thinking which may hinder the way professionals collaborate (D’armour and Oandasan, 2005). One way to overcome this is by introducing inter-professional education. This is a widely accepted method and has been defined as when students from multi professions learn about, with and from each other to improve outcomes and to enable effective collaboration (World Health Organisation – WHO, 2010). However, this approach in itself has barriers to overcome. Competition as opposed to cooperation may occur and logistics of timetabling, financing and differences in educational institutions could be problematic.
Legislation such as the Equality Act (2010) and NHS outcomes frameworks (DH, 2014) call for inequalities in healthcare to be addressed. Emerson et al (2012) have adapted this legislation to develop the Health Equalities Framework (HEF) and identified determinants of health inequalities; these include social, biological, communication, lifestyle and quality of service. Ernie is at risk as he falls into all five of these categories. Applying the HEF helps to identify patients at risk, allows intervention and has economic benefit. Although originally proposed for people living with a learning disability, Hebron (2011) claims that it can be applied to any individual at risk of inequalities in health.
All healthcare professionals should be aware of inequalities and have a duty to safeguard patients, particularly those regarded as vulnerable (DH, 2011). In order to effectively achieve this, partnership working is required to facilitate the exchange of information, effective decision making and timely interventions (Brammer, 2014). Ernie appears to be self-neglecting; this was flagged up by the nurses but he refused extra help. He is deemed to have capacity therefore his autonomy was respected. Ernie relied heavily on carers coming into his home to care for him on a daily basis. Cass (2012) identified that carers receive minimal training for safeguarding, making it difficult for them to recognise his safeguarding requirements. Residential care homes locally to Ernie were enlisted in a quality in care model for safeguarding which could have benefitted him. Other vulnerable individuals however, miss out on this due to the location of where they live (Betts et al, 2014).
It is also important in this situation to remember Doris. According to Carers UK (2009) there are approximately six million carers in the UK providing care for a relative. The Carers Act (2004) states that all carers are eligible for an individual assessment of their needs; this is applicable for those living in England and Wales. It may be appropriate for the district nurse in charge of the care to make an appropriate referral to local social services for this assessment to take place. Other ways in which the nurse can support the carer is by providing information and teaching nursing skills they are often required to undertake (Bee et al, 2008). James (2014) conducted a literature review which concluded that carers feel that coordination of services is very important to them, along with respect and information provision. The Expert Patients’ Programme (2009) also offers support by running a course to support the carers needs, known as ‘Looking after Me’. Case management can also offer benefits to the carer through providing educational support and psychosocial support. Offredy et al (2009) claims that carers alongside patients reported enhanced care and support. This is particularly important as Nicol (2011) suggests that carers are at a higher risk of stress – those looking after people with a mental health condition are particularly vulnerable.
The NMC (2008) state that nurses must use reflective practice to learn from their experiences. I will now reflect on my attitude towards working with someone with complex needs using the Gibbs reflective cycle (1988). The team looking after Ernie did not accelerate his care or consider a different approach for him. Instead we all became increasingly frustrated. It is good that this did not hinder the care Ernie received which was always delivered in a compassionate manner. However, looking back we could have reflected upon our attitude and come up with a more effective solution. We all have our own theories about people and how they should behave (Gross and Kinnison, 2007). As a team looking after Ernie it was easy to perceive him as the non-compliant diabetic who was hospitalised as a result. Our tendency to stereotype can prevent us from seeing the true needs and individuality of a patient (Barker, 2013). If faced with a similar situation in the future I would recognise my prejudices and seek to build a mutual trust and empathetic relationship between the patient and the larger MDT in order to facilitate better team functioning and outcomes for the patient.
In conclusion, the number of patients living with complex care needs is vast. The physical impact this has on the patient is huge but it is important not to neglect the psychological and social implications. In order to improve quality of life for these individuals the care they receive needs to be integrated. Healthcare professionals should collaborate effectively and communicate accordingly. This can help to empower the patient to self manage which can also be supported with the aids of technology. When using a framework such as the Kaiser Permanente it is recognisable when a patient requires escalation of care such as case management. Case management is an effective way of reducing hospital admissions and can stream line the care provided. When dealing with vulnerable patients it should always be at the forefront of healthcare professionals mind to safeguard and address any inequalities. It is important in the whole process not to neglect the carers and offer them support too. Healthcare professionals have the duty to reflect upon their practice and not allow prejudice or stereotyping to impact upon the care they give.
