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COPD SERVICE RE-DESIGN
Dr Mukesh Singh
GP Principal & GPwSI Respiratory Medicine, Horse Fair Practice, Rugeley
Clinical Lead LTC & Governing Body member Cannock Chase CCG
COPD
DRIVERS FOR RE-DESIGN
835000,
Severe
Disease*
3 Million
SUBCLINICAL COPD
Clinical COPD - Tip of the Iceberg
DOH DATA 2011
• The 2009 General Lifestyle Survey suggests that people with LTCs account for:
• 50% of all GP appointments
• 64% of outpatient appointments
• 70% of all inpatient bed days
• In total around 70% of the total health care spend in England (£7 out of every £10) is attributed to caring for people with LTCs
• This means that 30% of the population accounts for 70% of the NHS spend.
Looking back to look forward:
Uncoordinated, outdated and over
stretched
•Increase in demand for services
•An unsustainable system
•Paternal culture of management
•Lack of incentives to drive
integration
•Demographic pressures
Transforming services for COPD
COPD What we did
•Clinically led service redesign
•Worked with multiple healthcare professionals and organisations to develop care pathways
•Joint business case for change
•Commissioning and delivery of a proactive and integrated community service
•Whole-system approach to managing patients with COPD
COPD What we’ve achieved as a health economy
• The redesign of the COPD pathway and integration of patient management has resulted in a 37.2% reduction in COPD emergency admissions activity over two years
• Delivery of agreed pathways
• Patients managed in their homes
The success of the reduction is attributed to the multi-disciplinary approach taken to redesign the pathway and the subsequent patient management
CCG 2012 /
2013
2013 /
2014
2014 /
2015
% difference from
12/13 to 13/14
% difference from
13/14 to 14/15
% difference from
12/13 to 14/15
STAFFORD &
SURROUNDS
296 228 186 -23.0% -15.4% -37.2%
COPD Primary Care
• POINTS programme rolled out in primary care which up-skilled GP practices in the use of spirometry to diagnose COPD;
• Self-management plans for COPD patients, rolled out as part of the innovations group, designed with the community respiratory team;
• Nurse Clinical Collaborative focusing on COPD. This was attended by Practice nurses, Community Respiratory Team and Respiratory nurses from Mid Staffs FT. The programme covered respiratory assessment, consultation skills, inhalers, medication reviews, self-management, exacerbations and case studies; and
• Practices also identified patients suitable for “Flo” Simple telehealth and practices have been given pulse oximeters and thermometers with the aim to empower patients to take more responsibility for their health and wellbeing and seek to improve healthcare use across the different health sectors.
COPD Community Care
• Continued delivery of proactive care, including MDTs with GP practices and pulmonary rehab;
• Step up of COPD patients went via the community instead of secondary care;
• Consultant-led outpatient appointments for COPD patients as part of an MDT with the community respiratory nurse specialists;
• Hot clinics for patients needing a rapid review by a Consultant; and
• Follow-up appointment from an emergency admission to be had in the community.
COPD Secondary Care
• CQUIN implemented to ensure all patients admitted with COPD were assessed and seen by a consultant in a timely manner (admission bundle);
• CQUIN implemented to ensure all patients discharged following a COPD emergency admission have been referred to the appropriate follow-on services including follow-up in the community, smoking cessation, pulmonary rehab, community oxygen services (discharge bundle); and
• Decommissioned COPD outpatients in a secondary care setting and re-commissioned in the community via the community respiratory team with Consultant oversight and access.
In a single UK primary care
cohort
Friday @ 18:00hrs… COPD patient + Feeling breathless + Confused + No integrated care plan
GP Pharmacy 999 Admission A&E
No record of
care plan,
unable to give
antibiotics
Closed Ambulance
visits patient,
takes to A&E
A&E assess,
not happy
with patient
SATs and
decide to
admit
Antibiotics,
more
confused,
long LOS as
SATs don’t
improve
Passing the buck costs big bucks!
COPD
Thank You
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