Coordinating value based care for Londoners with COPD and asthma

Dr Louise Restrick, Co-lead LRT Integrated Consultant Respiratory PhysicianWhittington Health & NHS Islington

Who are the Londoners living with respiratory disease and what are their needs?

• People living with disabling BREATHLESSNESS

• Difficult home and social circumstances – often alone

• Quietly stoical and brave

• Tobacco (and cannabis) dependent

• High mortality with unpredictable disease trajectory

Respiratory failure - heart disease - cancer

• Multiple long-term conditions ie multi-morbidity

• Mixture of physical and mental illnesses

• Emergency admissions with frightening breathlessness +/- respiratory failure

‘I don’t want to die’

‘breathlessness is frightening and disabling’

‘hospitals and GPs don’t talk to each other enough’

What do patients & families tell us about their needs…

Language: Fear … and Hope

and aligning agendasPatients’ concern is breathlessness…

Frightening

Clinicians focus on respiratory failure

Frightening

Value Framework

Health Outcomes

Patient definedbundle of care

CostValue=

Health Outcomes Cost of delivering

Outcomes

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

A respiratory provider manifesto I am a long term conditions clinician I care about value I know how to assess and support patients and drive improvements

I work in a team

I personally deliver high value care

Kindness

Respect

Empathy

Dignity

Interest

TRUST

Respiratory teams committed tocare delivered with KREDIT*

*Whittington Health, London Respiratory Team and …

Approach to patient care and team work ...

eg Schwartz Rounds

Londoners dying from smoking

‘1 in 5 deaths due to smoking’

Respiratory Disease

Cancer

Cardiovascular disease

Mental illness

COPD ‘Value’ Pyramid

The low value pyramid?

Representation based on national GP contract data and locally retrieved data

Tools for coordinating value care:CCG dashboards - Tower Hamlets

Network 1 Network 2 Network 3 Network 4 Network 5 Network 6 Network 7 Network 8 Borough Total

April 39.08% 41.02% 32.35% 34.00% 38.87% 42.86% 38.63% 43.06% 38.76%

May 41.13% 40.68% 32.84% 34.41% 39.09% 43.09% 38.72% 43.36% 39.11%

June 41.11% 40.96% 31.73% 33.41% 37.94% 42.91% 39.11% 43.49% 38.84%

July 41.18% 41.71% 33.65% 33.41% 38.96% 40.82% 38.87% 43.20% 38.98%

August 40.20% 41.92% 33.96% 33.33% 38.31% 41.87% 39.12% 43.33% 39.00%

September 38.87% 42.03% 33.18% 34.73% 41.71% 43.15% 38.88% 43.85% 39.64%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

%ag

e o

f p

atie

nts

Confirmed COPD registered patients that are current smokers

40% smoking prevalence in people living with COPD

Tools for coordinating value care:CCG data - Islington

Tools for co-ordinating value care:

Systems & Quality Improvement

Academic Health Science Centres & Networks

Local Enhanced Services:

COPD & Quit Smoking

NHS Innovation Challenge

Awards 2012

Practice NursesGPs

Earlier Diagnosis

Tools for coordinating value care:National COPD Audit

2010 ERS Audit

Tools for coordinating value care:BTS National Asthma Audit‘Smoking status incorporated into the 2011 audit…

32.5% patients admitted to hospital were current smokers; 18.8% ex-smokers..’

60% asthmatics admitted to one inner London hospital current smokers

Changing how we think about smoking

Tobacco dependence

Sick smokers are admitted to hospitals - acute and psychiatric

Evidence based quit smoking treatment is the most important treatment for sick smokers:

Behaviour change support and quit smoking medication

Our clinical work - not just quit smoking advisors…

‘Smoking kills, stopping works’ Sir Richard Peto 2012

• Worsening/exacerbation of long-term condition

• Multi-morbidity

• Mix of physical and mental illnesses

• High readmission rates

…for other reasons

• High but unpredictable mortality

• Tobacco (and cannabis) dependent

Why do Londoners with emergency respiratory admissions need co-ordinated value care?

*Krumholtz NEJM 2013;268:100-102

Respiratory Pharmacist

64-71% re-admissions different reason*

Developed by CLARHCHopkinson et al Thorax 2012:67:90-92

Tools for co-ordinating value care:

COPD Discharge Bundle

*Jiminez Ruiz et al Nicotine and Tobacco Research 2011

~500 smokers with severe COPD*10 intensive interventions with

medication

44% quit at 6/12 with NRT60% quit at 6/12 with varenicline

Co-ordinating value care: Quit smoking advisors working with sick smokers as

in-patients

Pharmacist BTS

ChampionCQIN Clinical

Lead

Developed by CLARHCHopkinson et al Thorax 2012:67:90-92

COPD Discharge Bundle

Pre Bundle % With Bundle %

18 100

14 68

55 98

59 91

41 39

Co-ordination not easy!

‘Breathe Better, Feel Good, Do More’’

Co-ordinating value care: Respiratory Physiotherapists

PulmonaryRehabilitation

Tools for co-ordinating value care: behaviour change & motivational interviewing skills

Co-ordinating value care: psychologists in & working with respiratory teams

Respiratory Team

Psychologist

Tools for co-ordinating value care: CQINs

Co-ordinating value care:

Respiratory Nurse Specialists

Community Respiratory Nurse Specialist

In-patient Respiratory Nurse Specialist

‘Hospitals and GPs don’t talk to each other enough’

Why aren’t we speaking to GPs on admission?

More than 1 in 6 people

admitted to hospital had

not seen their GP in the

previous year

Why aren’t we connecting patients with their GP?

Why aren’t we speaking to GPs at discharge?

Tools for co-ordinating value care: electronic patient records

BTS AWARD for INTEGRATION of Respiratory Services 2013

Implementing a COPD disease management system in inner NW London to improve communication and care

Enhanced Recovery

Care planning conferences …Shared decision making: agreed shared agenda

Identify & address treatment and care gaps & needs

SocialWorker

Mental Health Key Worker

Quit Smoking Advisor

Consultant Psychiatrist

… with patients & family

Occupational Therapist

Hospital & MH Social

Worker

Tools for co-ordinating value care: coordinate my care

COPD template

My team or I can lay hands on …

A pulsoximeter . A contact for someone who can use a spirometer . A COPD/asthma action plan . A range of quit smoking products . A spacer . Stories and testimonies about PR . Registers of people with asthma, COPD, their smoking status and those at the end of life . An ICS safety card . A discharge bundle . LRT and Impress products . Phone numbers or an online resource for: stop smoking service, PR team, IAPT or CMHT, social care, carer support, blue badge co-ordinator, palliative care . Commissioning tools that enable improvements e.g. CQUINS/LES/LIS/NIS/DES . Tools that empower patients

‘Care is only integrated when people want it to be, otherwise it does not

happen …’ *

*LRT feedback from Londoners living with COPD 2013

Coordinating value based care for Londoners with respiratory disease ...

Kindness

Respect

Empathy

Dignity

Interest

TRUST …not only clinicians who make it happen