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Breathlessness Service

Wigan Borough CCGWendy Fairhurst

Clinical Director

Health First ALW CIC

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Health Equity Audits COPD and Heart Failure Deprivation Low prevalence High Admissions Excessive mortality rates

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Why Breathlessness? Start from symptom based approach rather than disease based

approach Problems with multiple pathology

Problems with diagnosis between cardiac and respiratory causes of breathlessness

Multiple pathologies managed individually not holistically

Limited post-exacerbation follow-up in practice teams – many factors

No detailed personalised management plans

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Feedback from Primary Care

Difficulties in the management of patients with multiple pathology

Patients referred to multiple hospital consultants and specialist nurses – inconvenience and confusing for patients – delays in appropriate treatment

Difficulties for some patients in accessing services

Travelling is difficult for this group of breathless patients

There are a high number of follow-up out-patient appointments. These are inconvenient for patients result in a high level of DNAs and are costly

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The sort of support that practices need Diagnosing more difficult cases – this includes especially differentiating COPD from asthma and heart failure, but also other conditions. Doing reviews and optimising care on patients with multiple co-morbidities – especially lung disease, heart disease, other vascular disease, diabetes and CKD

Doing reviews that go significantly beyond what is required for QoF – especially post exacerbation reviews that analyse causes of exacerbations and devise a plan for preventative measures

Identifying high risk patients - Just working with those patients who have been admitted is not enough – most of the year’s admissions were not identified from the lists of previous admissions.

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Principles Integrated working Early and accurate diagnosis Service based in Primary Care Active searching for patients in Primary Care who may be at

risk of deterioration Reviewing difficult cases in Primary by specialist nurses –

working alongside practice teams Giving each patient a self-management plan Consultant – led clinics in Primary Care – leading to more

integrated working Reviewing patients post-discharge in Primary Care Developing clinical resources for use within Primary Care

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Integrated Working

Patient journey – not clear and equitable across the borough.

Working with other agencies ( Primary Care, Secondary Care, Tier 2)

Need to eliminate duplication

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Early and accurate diagnosis Previously 6 attendances to diagnosis One stop shop diagnosis of Heart Failure

and/or respiratory disease Working with acute trust and community trust

to deliver the service in Primary Care Screening

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Diagnostic Service Pathway

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Service based in Primary Care

Support and mentorship. Up- skilling – working alongside staff in Primary Care

Training days Key role of practice nurses Mentorship for Gps and practice nurses Training for practice staff

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Active searching for patients who may be at risk of deterioration in Primary Care Preventing deterioration Searches Not waiting for referrals

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Assessment in Primary Care by Specialist nurse

Reviewing difficult cases in Primary Care by specialist nurses – working alongside practice teams (helps with up-skilling) – leading to more integrated working

Causes of exacerbations (medication/environmental) Optimising medication Patient education and empowerment Giving each patient a self-management plan Work with INT project

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Developing clinical resources for use within Primary Care

Guidelines for the treatment of exacerbations Cold weather warnings Desk top guidance Long term conditions template

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Consultant – led clinics in Primary Care leading to more integrated working

Consultant – works in different practices around the locality on a twice monthly basis

Direct communication with GP’s and practice teams

Mentorship Care Closer to home 2 week waiting list

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Reviewing patients post-discharge in Primary Care

Preventing re-admissions and further exacerbations

Duplication Working with Acute Trust

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Pilot

£121k verified savings ( unscheduled admissions, outpatients and medicines management)18/24 practices.

£180 – estimated - if all 24 practices had been involved

12 month period ( 6 month set up time) Based on one HRG code – J44 ( COPD

admissions) Initial difficulties in integrating with secondary

care ( COPD unit, discharge information)

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Diagnosis service results

Referred to service

New COPD 

COPDDiagnosis confirmed Treatment optimized

NewAsthma

Asthma diagnosis confirmed treatment optimized

Heart Failure

Other DNA Under investigation

282 88 29 27 13 35 43 12 35

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Qualitative resultshighlights

Improved data input and data collection in Primary Care ( e.g. recording of exacerbations)

Increased prevalence for all 3 diseases ( more accurate diagnosis, picking people up early, early treatment)

Average age of diagnosis reduced Increased referrals to smoking cessation and

pulmonary re-habilitation