There has been an increase in respiratory specialists working within community and primary care conducting "virtual" clinics alongside GP in their practices. However there are different interpretations of what a "virtual" clinic is and a need to define this clearly amongst each other and the wider care community.
As management of chronic diseases moves towards primary care, Seema and Sarah considered it important to develop a clear and consistent approach locally to what constitutes a virtual registry review, and to use them as a vehicle to support and up-skill GPs, connecting them to secondary care specialists and the wider multi-disciplinary team. This programme was part of the 'Connecting Care for Adults' program - CC4A.
Welcome to Respiratory Futures. Can you provide an overview of the connection between CC4A and Imperial College NHS Trust; how did you begin working on this project together?
Connecting Care for Adults came from an education project grant application made by Dr Sarah Elkin and Prof Jeremy Levy, both consultants at Imperial College NHS Trust. The project was hosted by the integrated care directorate, led by Anna Bokobza.
The application - centred around respiratory, kidney disease and heart failure - was successful, and funding from Health Education England North West London was awarded to 'Integrating care: taking specialist out of hospital for complex adult physical health' for a 12-month period starting in June 2017.
The project scope was to provide structured specialist support to primary care to improve management for chronic conditions and develop relationships at the primary-secondary care interface. It aimed to create a culture of collaborative working, up-skilling both workforces to adapt to new ways of working that would ultimately result in delivery of better care, more efficient patient pathways and improved patient and staff experience. The initial results and feedback from primary care were positive and additional funding was awarded in November 2017 to extend the project.
A project manager was appointed and, after engagement events with primary and secondary care stakeholders, a project plan formulated that identified three key delivery areas:
1] Conduct multi-speciality Virtual Registry Case Reviews at GP practices
This was based on a paediatric integrated care initiative at the Trust: Connecting Care for Children (CC4C) https://www.cc4c.imperial.nhs.uk, but it became clear that the format of the multidisciplinary team case discussions were not ideal for individual chronic disease up-skilling.
As a project team we were keen to develop a model of care that could be explained, evaluated and rolled out in different areas and conditions. We therefore developed a toolkit for standardising the process of Virtual Registry Case Reviews and ensuring that changes made as a direct result of the reviews were documented and evaluated. The importance of evaluation was a learning point from other initiatives in that there is a need to provide proof of concept to support commissioning for sustainability.
We drafted disease-specific proformas that allowed the specialist to review the patient’s case, adhering to national and international guidelines for management of their primary diagnosis and which would also ensure a robust checklist of criteria for review. The proforma guides the specialist through the verification of diagnostic and pathological tests to confirm accuracy of disease diagnosis and severity.
There is a section to record prescribed medications with advisory changes documented, such as change in inhaler or a decrease in inhaled corticosteroid and the need for referrals for pulmonary rehabilitation or further imaging/ tests (such as repeat spirometry or full lung function) with documentation on GP records of prospective case planning and management.
COPD pro-forma for virtual review (download from end of feature)
The proforma has had much iteration as ideally it should be limited to tick box entry rather than extensive documentation, as with the intended roll out across NWL would warrant continued data collection.
The virtual registry review format within the CC4A Registry Case Review Clinics PDF explains the processes to generate a list of cases to review.
Process map for registry case reviews (from CC4A Registry Case Review Clinics PDF)
Prior to the specialist attendance, the practices are asked to run a search of their SystemOne or EMIS database to produce a list of cases to be reviewed and discussed. These searches are designed to identify those patients that may be more likely to have sub-optimal outcomes.
The query should be for those with diagnostic Read codes for COPD and/or asthma and:
i] Prescribed high dose inhaled corticosteroids e.g. Seretide Evohaler 250, Seretide Evohaler 500 or equivalent generics
ii] Requiring ≥3 rescue packs or steroid courses in last 12 months
iii] MRC dysponea scores >3
From this report the following information is extracted:
- Patient demographics – NHS number, first name, surname, date of birth and age
- Diagnostic Read codes – asthma/COPD
- Inhalers (LAMAs, LABA/ICS and SABAs) – drug name, dose
- Prednisolone prescriptions
- Date of last review – date (as per QoF codes for annual COPD and asthma review)
- Smoking status - status
- MRC score
These patients can then be discussed at the primary care meeting alongside the extended MDT with recognised teaching moments, such as spirometry for diagnosis, new inhalers, lowering ICS and why, what pulmonary rehabilitation is and why/how to refer. Additional cases to discuss may be tabled by GPs and other primary care staff that they feel would benefit from a specialist clinical management opinion.
A core group comprising of GP, pharmacist with secondary care specialist should be present at registry review. The secondary care specialist can be accompanied by senior specialist trainees to support their specialist training. All primary care staff, including practice nurses and healthcare assistants, in particular GP trainees, are invited to attend to encourage engagement with specialist care and to promote improved relationships to support the development of integrated care.
The model is also supportive of the STP plans across North West London that use a more holistic approach to care for patients with long term conditions, including primary care. This model of care will provide the basis for a closer working relationship between specialist and primary care. You can read the learning outcomes from registry case reviews.
2] Development of educational resources and teaching
It became apparent that there were common themes emerging from the registry reviews. We therefore developed monthly bite-size news letters to send to all GP surgeries to help widen learning and lessons learnt. We have analysed referrals to out-patients clinics to identify core themes.
During engagement events, GPs told us that they would like to embed referral and treatment algorithms into GP records. We have co-designed these with primary care to ensure that patients have appropriate diagnostic tests performed prior to referral, and that those seen in secondary care warrant specialist input to their management.
We have also developed bite-sized videos within each long term condition, focussing on specific areas of need highlighted by the registry reviews, including accurate diagnosis and appropriate medication.
3] Engage and empower patients to encourage self-care
In respiratory disease, there is data to suggest that individuals collect less than 50% of their inhaler prescriptions. It is not surprising, therefore, that they subsequently experience acute exacerbations of their disease, often out of hours for emergency care. As such, strategies that empower patients to take an active role in the management of their long term condition are paramount. As part of the project plan, we are evaluating a digital self- care tool ’MyCOPD’. We will be reviewing patient activation scores before and after access and use of the tool as part of the patient evaluation. It is currently unclear which COPD patients use and find digital technology useful. This evaluation may help define this further.
4] Pharmacist-led medicines optimisation
This has involved a cardiologist specialising in clinical pharmacology supporting a pharmacist in GP practices to optimise drug agents where the diagnosis of hypertension has been confirmed by a clinician. We are piloting with hypertension and aim to add more conditions as we enrol other specialists and agree therapeutic drug hierarchies.
How does the toolkit work and how can others utilise it?
The toolkit is essentially the format to the Virtual Registry review and the proforma, used together. The benefits are that there is standardisation of application.
The proforma is now at version 7 with every iteration refining what is now primarily a tick box with the only written entries required being actual inhaler names. The documents are available in the "further reading and downloads" section below.
We hope this simple approach will encourage its consistent use by clinicians and community healthcare professionals and give better understanding of how to set up and run Virtual registry reviews.
When developing the CC4A what factors did you have to be aware of; were there any surprises?
The main challenge was the initial engagement of primary care in the process. However, we found once the GPs became aware of the initiative there was a large flurry of requests. This was further assisted by the introduction of an enhanced contract for COPD and asthma care locally. There is also an administration element to the process in booking the review and ensuring the specialists were free.
The main surprise were the number of patients that were misdiagnosed within the primary care record and had been for many years. This was both by GPs and junior doctors in A&E. The diagnosis then becomes accepted into the GP record and continued on without real challenge. The Virtual registry reviews were an excellent way of sorting out the diagnosis and ensuring correct care was delivered.
We presented a summary of our main achievements to a BMJ judging panel outlining what we did during the registry reviews. This included feedback from GPs as well as the educational resources produced.
What’s next; do you intend on reviewing the toolkit at any point?
We are still using the toolkit and are in the process of a system-wide economic evaluation, and are aiming to rollout across North West London CCGs. We will continue simplifying the proformas and are able to add data fields so this could be used to focus on particular areas with a locality or sector that has specific issues.
Further reading and downloads: