Collaborative care for people living with chronic long-term conditions in Tower Hamlets: Protocol of a feasibility and acceptability pilot

Problem

Many people living with long-term conditions experience ill health. Both the UK Quality Outcomes Framework (QOF) and nurse-led personalised care planning are considered the cornerstones to improve patient outcomes in general practice (GP). However, up to one in five patients with chronic disease continue to be at risk of poor physical health, and about half suffer from anxiety and depression. Tower Hamlets, a highly-deprived London borough, has seen high burden of disease associated with particularly poor health outcomes. Therefore, questions remain as to how to further improve care delivery, given increasing complexity of care and lack of vocational training in mental health for GP staff. The National Institute for Health and Care Excellence (NICE) has recommended collaborative care to address the needs for people living with long term conditions, yet psychological wellbeing practitioner models of collaborative care have failed to improved physical outcomes or may worsen people’s mental health.

Approach

We follow the MRC framework for complex interventions to develop a pilot protocol for clinical health psychology (CHP)-enhanced, personalised care planning in inner-city general practice. We aim to 1) assess the feasibility and acceptability amongst GP staff and patients of this intervention and 2) set up the processes and data collection for a future effectiveness and cost-effectiveness study. Study location is two Tower Hamlets GP-networks. Study population is patients aged 17 and above who suffer from either COPD (modified MRC score ≥2; network 7) or type 2 diabetes (glycated haemoglobin [HbA1c] ≥75 mmol/mol PLUS ≥12 GP appointments in the last 12 months; network 2). We have integrated a CHP within each network to deliver the following support: Staff capacity building including education and group training sessions for practice nurses, case notes reviews, shared reflective learning and case discussion, and participation in multi-disciplinary team meetings; and direct patient care including face-to-face consultations and patient group meetings.

Findings

We will report on the following outcomes: 1) Qualitative: including staff acceptability and satisfaction (semi-structured interviews, focus groups, and online questionnaires), and degree of CHP integration and role development within the networks; before and after measurements of COPD Assessment Test, Diabetes Distress Scale, PHQ-9, GAD-7, Work and Social Adjustment Scale; and Risk Assessment; 2) Quantitative: including number of hospital admissions, accident and emergency attendances, face-to-face GP consultations, and care plans completed (both COPD and diabetes); numbers of patients referred to pulmonary rehabilitation, pulmonary rehabilitation completed, flu vaccinations received, and smoking cessation (COPD); and numbers of patients with foot check completed, HbA1c <75, blood pressure ≤140/80 mm Hg, and cholesterol ≤4 mmol/L (diabetes); and 3) Difference in costs and benefits using historical and matched local geographical controls.

Consequences

Study results will inform future NIHR programme grant development for a definite effectiveness and cost-effectiveness study.