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Designing the service around the patient

A nurse-led rheumatology team has cut waiting times and improved clinical outcomes by moving a hospital-based service into the community and redesigning it to meet patients’ needs. Led by rheumatology nurse specialist Sarah Critchley, the team from Pennine MSK Partnership has replaced a reactive service with one that is systematic and holistic. The team won the Nursing Standard Community Nursing Award earlier this month.

A nurse-led team that moved a hospital service into the community and reshaped it around the needs of patients, won Nursing Standard’s prestigious Community Nursing Award.

The award, sponsored by All-Bran, went to the primary care rheumatology team at Pennine MSK Partnership, which established the service in 2011. Since then, the team has cut waiting times, increased the duration of appointments, and developed a comprehensive package of care to help patients manage their long-term conditions, scoring highly in terms of patient satisfaction.

Picture credit: John Houlihan

The service was created in response to the increasing waiting times for rheumatology patients at the Royal Oldham Hospital in Lancashire.

‘The care of patients with chronic diseases was reactive, unplanned and episodic, resulting in the inappropriate use of secondary care services,’ says Sarah Critchley (pictured), who leads the service’s team of rheumatology specialist nurses, infusion nurses, an outpatient nurse and healthcare assistants.

‘I worked at the acute trust as a rheumatology nurse and saw at first hand the issues surrounding waiting times of six to nine months, the lack of patient pathways and the impact on patient care. Three quarters of clinics were used for routine follow-up, leaving little space for patients requiring urgent review during disease exacerbations.’

Ms Critchley says the nurses wanted to move away from this reactive approach and towards systematic, patient-centred care. ‘We wanted to provide better clinical outcomes, deliver high quality care, incorporate shared decision-making and improve patient experience.’

First steps

Ms Critchley reviewed the community-based service as part of her master’s degree dissertation, and then left the acute trust to set up the nurse-led service at Pennine MSK Partnership. The partnership is commissioned by Oldham Clinical Commissioning Group to provide care for patients in orthopaedics, rheumatology and chronic pain at several sites in and around Oldham.

New pathways, policies and patient group directions were developed. One major success involved switching patients from a weekly hospital appointment when staff would administer intramuscular methotrexate to patient-administered subcutaneous injections, saving more than £1 million.

‘We also devised a more holistic approach to health, in partnership with other NHS services and voluntary organisations,’ says Ms Critchley.

Nursing Standard thanks Kellogg’s All-Bran for sponsoring the Community Nursing category in our Nurse Awards 2015

Before their transfer to the new primary care service, patients were sent an information pack explaining the changes. ‘They knew the rheumatology team, so we reassured them it would be the same team providing their care but that we were aiming to improve the service,’ she says.

The trust can see that we provide certain elements of the pathway more efficiently

The transfer of 1,686 patients was completed in September 2011 and the secondary care service was decommissioned.

Under the nurse-led pathway (see case study box), the team aims to give patients an appointment within one week of referral. All referrals are triaged by nurses or physiotherapists to ensure patients with inflammatory arthritis have rapid access to care.

Case study: the nurse-led pathway in practice

A 45-year-old, self-employed builder was referred to Pennine MSK Partnership with a three-month history of multiple joint arthralgia with associated synovitis. He was seen by a consultant rheumatologist within three weeks of referral and diagnosed with rheumatoid arthritis.

The patient was placed on the nurse-led pathway and was seen within a week of diagnosis for drug education and disease management. He was started on combination disease modifying anti-rheumatic drugs and oral steroids. However, he continued to struggle with multiple painful and synovitic joints and overwhelming fatigue, and had to give up work.

At this point, he was referred to an occupational therapist, a physiotherapist and a podiatrist, who helped him cope with the physical and psychological impact of his long-term condition. He was also involved in the service’s brief intervention for smoking cessation.

The patient was reviewed in the nurse clinic every four to six weeks for rapid escalation of his treatment and assessment of disease activity.

At six months, the patient’s disease activity score (DAS) was 5.92; he was started on biologic therapy, as recommended in National Institute for Health and Care Excellence guidance.

Since starting on biologic therapy, his DAS has reduced to 1.52 (indicating disease remission). He has now stopped using oral steroids and has returned to full-time work as a builder.

Sarah Critchley (centre) and the team she leads at Pennine MSK Partnership

Patients are reviewed every four to six weeks until the disease is well controlled. If the patient is stable for 12 months, they are placed on annual review, but still have access to the team via the advice line, if needed. If the patient’s disease remains active despite optimal treatment, or if co-morbidities have been detected, the patient is reviewed by a consultant.

‘Senior nurses work autonomously with the patient, referring to the multidisciplinary team as necessary and supporting and promoting self-care,’ says Ms Critchley.

She adds that close collaboration with other organisations has proved vital in this self-management goal. ‘Our patients are able to access support for self-care and psychological needs through new partnerships with voluntary agencies. They have the opportunity to see many different professionals, such as occupational therapists, podiatrists and physiotherapists, and they have longer appointment times.’

The extensive network of support now available to patients includes employment advisers, social services and benefits agencies, community health professionals, a falls team, smoking cessation services and leisure services. ‘We have also commissioned psychological medicine, which has been invaluable for our patients in supporting them to cope with the impact of their long-term conditions,’ says Ms Critchley.

Brief interventions are another feature of the team’s work. ‘Through our smoking cessation campaign last year, we asked patients if they smoked and offered brief intervention to those who did, signposting cessation services.’

Patients also have access to research trials and to disease-modifying, biologic and injection therapies. Clinics offer flexible appointment times between 8am and 8pm, and telephone review appointments are available.

Effective triage

There has been a 58% reduction in the average waiting time for first appointments. ‘Effective triage means that patients are seen by the right person at the right time,’ says Ms Critchley. ‘This results in shorter waiting times for patients needing to see a consultant for diagnosis or assessment of complex medical needs.’

The team contributes to the national clinical audit of early rheumatoid arthritis, and its results are impressive: 80% of patients are seen within three weeks of referral, compared with 41% nationally, and 92.5% of patients are offered educational or self-management appointments within one month of diagnosis, compared with 58.6% nationally.

As well as working with district and practice nurses, the team has maintained a strong link to the acute trust, enabling rapid access to inpatient treatment when required.

‘Initially, the trust looked on us with some suspicion as competition,’ says Ms Critchley. ‘But as we’ve grown, they can see we provide certain elements of the pathway more efficiently, allowing the trust to concentrate on the parts only it can provide – the admitted patient journey.’

Empowering patients

Pennine MSK Partnership executive director Anne Browne says the ‘highly skilled, knowledgeable and, most importantly, compassionate’ team provides a truly holistic approach to patient care.

Nurse consultant Ms Browne adds: ‘The team endeavours to be responsive to need, whatever that may be, while empowering the patient to self-manage whenever appropriate.

‘Motivational interviewing and shared decision-making are embedded in consultations, so the patient is a true partner in their own care and treatment planning.

‘Patients who had been in the service before the nurse-led pathway always compare the new service favourably.’

The team was an early user of the NHS friends and family test, which gathers feedback. Test results revealed that 95% of patients were extremely likely or likely to recommend the service.

But the team is not resting on its laurels. Each month, 100 patients are selected randomly to rate their satisfaction with the service. In 2014, 95% of respondents were completely satisfied or satisfied with their care. In relation to shared decision making, 83% felt that their care was collaborative.

This feedback is not just collected – it is acted upon, stresses Ms Critchley. ‘We recently appointed two female podiatrists in response to a patient comment that all our podiatrists were men, which was difficult for some of our black or minority ethnic patients.’

Nursing Standard is not alone in recognising what the rheumatology team has achieved. It holds the Customer Service Excellence Award, and in 2014 the British Society of Rheumatology awarded the team best practice model for an outstanding community service.

Continuing development

Ms Critchley says the team has offered help to other areas that want to set up a similar service, and there are also plans to develop what its service offers. ‘We have a model of continuous service improvement, have increased our nursing workforce, have nurse prescribers and we ensure externally validated training and the assessment of competencies underpin extended scope practice.

‘The entire team are supported with their continuing development. Senior nurses, healthcare assistants and the infusion team all have access to training and education.’

And the team is extending its array of partnerships to make care even more holistic. ‘We are working with Oldham’s Health and Wellbeing Service to promote healthy lifestyles and increase physical activity levels.

‘We are also working with employment advisers to help patients remain in work, and those wanting to return to work, as 40% of working people with rheumatoid arthritis stop work within five years of diagnosis. One in seven give up work within one year of diagnosis.’

For Ms Critchley and her team, receiving the Nursing Standard award has provided an opportunity to share their holistic model and potentially benefit even more people. ‘We hope our approach will reach a wider audience’.

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