Chronic disease management: the role of care pathways

First published June 2007, updated January 2022

Key points:

• There is a pressing demographic requirement to reconfigure older people’s services and develop services that cross traditional tiers of care.
• Disease management teams need to be created.
• Managing more of the care in the patients’ home would require investment in remote monitoring such as telemedicine.
• Blockages in the system result in inequalities in health, delayed discharges and unequal spending of financial resources.

By 2020, the over 85 years section of society will double and by 2024, the number of people over 65 years will rise by 21 per cent. This demographic statistic should not be seen in a negative light, but more of a challenge to redesign services. For example, we know that 90 per cent of patient care for all age groups already takes place at a primary care level although community services account for less than half of NHS funds. This means it is very expensive to look after patients in hospitals, which brings into focus that patients should only stay in hospital when it is absolutely necessary. We also know that older people are high users of urgent care.

Challenges

National standards for the provision of care for older people and critical reports on the care of older people such as the Rowan Report have helped to deliver a more evidence-based approach to care. By definition this has taken out some of the outlying types of practices that skew care into unacceptable practices. Lots of work has been put into reducing delayed discharges for older people from medical and mental health wards (Table 1).

The medical workforce is also changing rapidly given changes in the consultant contract and the reduction of direct clinical contact time with DR A patients. The European Working Time Directive is also having an impact on the provision of junior medical staff. No longer do they provide the service element to care as their clinical time is taken up with supervised practice. The recruitment of consultants psychiatrists has also been problematic and the future training trend shows a projected shortfall for the next 10 years.

A pressing demand is one of demography with a projected rise in the older age population. This will place considerable strain on local health services and test the foundations of the NHS structure. Redesign of older people’s services where more people are supported at home or as close to home as possible is one way forward.

In order for services to change, we need to be clear what elements of care can be delivered by nursing staff, carers and patients themselves. Another way of interpreting this is to consider what aspect of care needs to be carried out by doctors. Care pathways can help to clearly identify what part of the care needs to be done by professional, carer and user groups.

Policy directives have been produced that set the stall for the development of older people’s services (Table 1). Current organisation of services will be unsustainable to meet the global demand anticipated over the next decade. We need to see radical changes to how and where care is organised. Tools to help service planners to do this are care pathways. Care pathways will also help clinicians to deliver care to set protocols so that care is provided that meets national standards, but also that is equitable.

Table 1. Supporting policy

The role of care pathways

Care pathways can be both a paper based and electronic form of recording the expected problems, interventions and outcomes for a specific diagnostic group. Care pathways have been developed for a range of mental health conditions such as schizophrenia and co-morbid learning disabilities. The development of care pathways leads some clinicians and managers to experience a sense of conflict, particularly over the content and speed of interventions to be delivered. However, the interesting aspect about care pathways is that they allow clinicians to see when the patient deviates from the expected course of treatment.

It is estimated that 75 per cent of patients within a defined diagnostic group should stay within a predicted course treatment. This estimation supports the concept that extended nurse practitioners or physician extenders can manage three quarters of healthcare, leaving the final unpredictable quarter to be overseen and managed by consultant medical staff with the aid of nursing staff.

Care pathways for older people

Some may argue that it is impossible to state what factors should be identified for treatment success or even factors that govern discharge. However, there has been some research on how older peoples’ teams set up and agree discharge outcomes and what predicts discharge. There have been examples of care pathways detailing end of life care and care of the older adult on medical wards. One notable example is the Liverpool care pathway for the dying. Some research suggests that 56 per cent of people expressed a preference to die at home although 56 per cent of people die in hospital with life limiting diseases. Hence the importance of clearly setting out the care and treatment most preferred by patients. Other care pathways have been developed to cover the admission and discharge of older people to and from hospital. A pilot of the care pathway indicated that variances from the established pathway had led to changes in the procedure and helped to improve the overall coordination of care. Notable problems in development included the lack of €˜buy in’ from all members of the team.

Evidence about care pathways is generally poor in terms of economic benefits. There is no clear evidence to suggest that they are effective in terms of patient satisfaction and the major problem is to do with methodological rigour of the studies. However, one can draw other benefits from care pathways such as their ability to outline what care should be delivered within set diagnostic episodes or mixed groups of diagnoses, i.e. complex care.

The different aspects of care required by older people obviously spans just one aspect of healthcare. Care pathways can be used to set standards and objectives for the level of care required at different parts of the whole system. This will prevent older people from being managed in inappropriate parts of the care pathway.

Changing the balance of care

There has been a tendency for mental health services to be categorised by barriers at an organisation level for example between the Local Authority, NHS, PCTs and voluntary organisations. Building better services for older people means developing services that are joined up. A natural tendency to bridge gaps in services is to create more teams but herein lies the tension as barriers are created. Care pathways can identify the interface issues between services so that they do not disenfranchise patients or lead to health inequalities.

Potential ways to overcome such organisational boundaries is to view conditions suffered by older people as a chronic disease and to take what is known as a population perspective in planning services. The overall aim of planning services around the disease type is to ensure that the artificial boundaries that exist between health and social care have minimal impact along the continuing of care. You also begin to recognise how many patients will need to be supported by this tier of service and then allocate resources to meet this accordingly.

Services need to be configured where disease management teams are created and where the responsible clinician is able to provide care, order tests and treat whether the patient is in primary or secondary care. For example, if a patient began to suffer from confusion as a response to a transient ischaemic attack, they could be admitted through a medical ward and their care could be managed through this hospital episode and then back to the patient’s home with follow up support.

Managing more of the care in the patients’ home would require investment in remote monitoring such as telemedicine, increased capacity in day care provision and a movement towards a much more integrated health promoting way of treating disease. The importance of developing a care pathway to map out service provision for older people becomes very important. Likewise the role of GPs in this process becomes fundamental as they need to be able to cross different services in secondary care.

Conclusion

The NHS is facing a demographic necessity to change from an illness service to a service that can support people closer to home and make them less reliant on acute care. It is no longer appropriate for patients to be managed in parts of the health system that are not able to meet their needs. Blockages in the system result in inequalities in health, delayed discharges and unequal spending of financial resources. Planning care within a chronic disease management approach and aided by care pathways will help to ensure that patients receive the highest possible standard of care in the most appropriate place. The beauty about care pathways is that they are able to determine standards for care at the diagnostic level as well as being used to bring about changes to the wider systems of care.