Welcome back to Respiratory Futures, Dr Gillian Lowrey. We heard from you in May last year about your oxygen-wristbands project which has garnered a huge amount of interest so we are very excited to hear about your ImpACT work. Can you give us a bit of background please?Respiratory RightCare Commissioning for Value data packs highlighted opportunities to reduce variation in non-elective admissions across Derbyshire. Local data analysis helped to shine a light on the problems that needed addressing and engagement with stakeholders encouraged a greater understanding of what wasn’t working well and why outcomes were not being achieved.
This information highlighted key problems that needed addressing which included:
- Not enough support was offered to patients at risk of a lung condition or following diagnosis.
- Patients were often reaching crisis point before receiving specialist support from highly skilled health professionals.
- The traditional way of engaging with patients was not effective in supporting those that were hard to reach.
- Opportunities to engage with patients at a time when behaviour change is more likely (a teachable moment) was not being harnessed.
- There was not enough collaborative working between GPs, practice nurses and respiratory specialists.
- The level of skills and competencies across health professionals was variable which consequently led to patients receiving inconsistent messages about their condition.
This consequently led to the development of a Respiratory RightCare programme in Southern Derbyshire CCG. This programme collaborated with a wide range of stakeholders inclusive of secondary care clinicians, ambulance services, psychological therapists, The British Lung Foundation, patient representatives, practice nurses, public health and commissioners.
Working with these stakeholders and drawing on their knowledge and expertise provided a significant opportunity to redesign the future of respiratory care so that it moved away from the reactive, episodic model of care that was in place to one that was more proactive and grounded in prevention.
It's great to see targeted use of the RightCare data, tell us what changes you made to the respiratory care.
The redesign of respiratory care was undertaken by a clinical advisory group who worked collaboratively to develop a future model of respiratory care, which focused on the areas of greatest opportunity. This model was based on NICE recommendations and Quality Standards along with the COPD value pyramid and national evidence based practice.
Whilst there was always the end point in mind relating to reducing non-elective admissions it was recognised early on in this process that this wouldn’t be achieved by focusing on developing a model of care that solely directed improvements towards this later stage in the patients pathway but that there was greater opportunity of success by focusing on the very start of the patient pathway; prevention and diagnosis.
It was the development of this model that provided the road map for the commissioning of services locally. This involved the realignment of resources and services to ensure that they were able to shift to population based care to help to define and deliver the right health outcomes for patients.
In support of bringing this new model of care to fruition additional investment was secured and market engagement was undertaken to determine whether the future direction for the model of care should focus primarily on COPD or include all respiratory conditions. The outcome of this engagement was for the future model to be fully inclusive of all respiratory conditions and associated interventions such as home oxygen and pulmonary rehabilitation.
This process has resulted in the implementation of a Place Based Specialist Respiratory Service which was tendered for in 2017/18 and awarded to IMPACT+ at University Hospital Derby Burton.
This service has implemented the following interventions aiming to improve patient care:
- Working with smoking cessation services and public health to promote lung health awareness to support prevention of lung diseases.
- A case finding approach using a range of tools including GRASP case finder in primary care, screening in high prevalence areas such as substance misuse services along with embedding screening for respiratory disease in smoking cessation services.
- Specialist MDT assessment for all newly diagnosed patients including access to newly diagnosed education groups for asthma, COPD or bronchiectasis.
- Pulmonary Rehabilitation delivered from public gyms, which provides access for all patients with respiratory disease with MRC 2 and above.
- Consultant led virtual clinics delivered within practices. Delivering monthly virtual clinics in each “place” to discuss complex cases, review diagnosis and review medication. These clinics allow systematic review of patients identified from practice level data e.g. those with COPD on triple therapy. The virtual clinics also provide opportunity for learning through case review and discussion and target high value evidence-based interventions.
- 7-day telephone helpline led by respiratory nurses, which is available for patients, GP practices, the ambulance service and other services requiring respiratory related support.
- Community social asset-based clinics led by respiratory specialists based on The Health Foundations ‘Making Waves’ model which targets hard to reach and vulnerable patients e.g. substance misuse patients.
- Specialist MDT assessment following >2 exacerbations to provide patients with a holistic review and an opportunity to further promote self-management and education.
- Specialist MDT assessment following admission to hospital to provide supportive discharge and follow-up within 2 weeks of admission.
- Fatigue and Breathlessness Groups for those with advance disease and heavy symptom burden who are not suitable for pulmonary rehabilitation. This is led by a respiratory specialist consultant and occupational therapist.
- Home oxygen therapy and domiciliary non-invasive ventilation therapy support.
- Education for health professionals, both face to face, mentoring and e-learning.
- Lung health events in primary care working jointly with smoking cessation services and targeting those who are known to have respiratory disease but are current smokers.
The service is delivered by a multi-disciplinary team which consists of; medical consultants, specialist nurses, physiotherapists, occupational therapists, fitness instructors and respiratory care assistants. The team is closely aligned to GP practices and co-locates clinics with Smoking Cessation services.
Alongside this a number of other initiatives have been implementation inclusive of:
- Inpatient Smoking Cessation at two acute hospitals.
- The formation of a Respiratory Practice Nurse Network, which is led by two practice nurses and supported by the IMPACT+ specialist service.
- Provision of respiratory Self-Management Plans to all GP practices.
- IAPT ‘integrated psychological service for long term conditions’ which was a pilot running till March 2018. Commissioned outside of the Rightcare programme of work
- Standardisation of the respiratory review template used in Primary Care.
Next steps include:
- Implementation of Hospital Outpatient Treatment Clinics for respiratory patients threatening admission.
- Commissioning of a respiratory diagnostic service inclusive of spirometry and FeNO.
Fantastic, and what results have you seen from this?
The IMPACT+ service has delivered the following outcomes between April 2018 and March 2019:
|
INTERVENTION |
OUTCOME |
|
Referrals to the service (excluding pulmonary rehabilitation and supported discharge) |
3810 |
|
Newly diagnosed assessments and education |
32 patients |
|
Pulmonary Rehabilitation |
1122 referrals 765 assessed to start programme 85% patients completing a programme. 70% reporting improvements in exercise capacity. 88% reporting improvements in functional status. 85% undertaking continuation exercise on completion. |
|
Virtual clinics |
207 cases have been reviewed 83 secondary care referrals avoided using vMDTs (40%) 47 patients had medication changed (23%) 52 patients had referral to pulmonary rehabilitation (25%) 42 new diagnosis confirmed (20%) 21/27 health professionals reporting finding the service extremely useful |
|
7 day helpline |
323 calls 12 admissions avoided |
|
Asset based clinics |
2 clinics established with a further plan to implement more clinics across different places. |
|
Fatigue and Breathlessness Groups |
43 patient attendances |
|
Patients reviewed with >2 exacerbations/year |
193 |
|
Post-hospital COPD discharge review <2weeks |
334 patients (98%) |
|
Outpatient attendances |
83 avoided (9 month) |
|
Non-elective admissions |
6% reduction in non-elective admissions across COPD, Asthma and Pneumonia. |
Patient feedback has included:
New patient education group
"I want to be able to climb mountains as I did in Wales. Now I want to climb Snowden. With the help I'm getting I will make it."
"Very helpful session - good to hear about other people’s experiences"
"Information given to take away will be very helpful to read through and refresh what was talked about during the session and for family members to read"
"Learnt a great deal about my respiratory problem, thank you"
"Fully appreciated the explanation of my COPD condition"
Pulmonary rehabilitation
“I have mowed my lawn for the first time in 5 years”
“What did you enjoy most? “Absolutely everything. The challenge, the group together, talking and mixing with others, sharing problems, laughing together, working hard, feeling proud, the music!”
“I can now realise the benefits of maintaining physical exercise and will continue. I can now push myself to keep getting fitter. I was once very athletic when young and now I feel very positive to continue”
“I would like to say a great big thank you for this wonderful experience of being offered pulmonary rehabilitation. After being discharged from hospital I felt very poorly and had no energy. I can honestly say that the past 6 weeks have made a great difference to me both physically and mentally. I have gained my confidence back and feel more positive to continue. I feel fitter and very keen to continue. Thank you to all the team. I am fitter and happy and more positive towards the future.”
Healthcare professional feedback has included:
“An amazing service and demonstration of primary and secondary care working together to deliver seamless service.”
“Very good to be able to discuss individual cases with colleagues and specialists.”.
“It provides an excellent opportunity to discuss our complex cases and to share our experiences and knowledge.”
“Even when they might not be your patients being discussed, you can still learn from them. Primarily, however, they are beneficial as are so thorough, much more like the idea of holistic care, with brain storming going on from the different clinicians, and to have immediate access to consultants from secondary care is a real treat.”
“A great resource for practice nurses and GPs, relaxed informative sessions, patient centred, and easy to refer to. A must for all nurses seeing respiratory patients in general practice.”
“Very educational and extremely useful for practices as gold standard advice given for patients condition and to both reduce waiting times for treatment and reduce need for secondary care referrals.”
“Myself and colleagues are finding these invaluable in enabling us to better manage ours patients and also from an educational point of view.”
Outcomes from other services/initiatives implemented
|
INTERVENTION |
OUTCOME |
|
Inpatient smoking cessation service University Hospitals Derby Burton |
76 patients achieving a 4 week quit 40 patients achieving a 12 week quit |
|
Patients with a self-management plan |
2016/17 3509 patients given a plan 2017/18 5990 patients given a plan 2018/19 6686 patients given a plan |
|
Respiratory Practice Nurse Network |
41 practice nurses who are members of the group. Quarterly meeting to share practice and learn from others. Establishment of a WhatsApp group. Supported by IMPACT+ specialist respiratory service. |
|
IAPT Integrated long term conditions pilot project (commissioned outside the Rigthcare steering group) |
45 patients with lung conditions attended and completed a psychological intervention. Of these patients there was a reduction in A&E usage – 70% in activity, 75% in cost and 60% reduction in activity and cost of non-elective inpatient admissions. Reductions in community referrals between 40-60%. For those patients who completed treatment within the integrated group the average cost savings equated to £852 per person which represents £1.46 savings for every £1 spent. |
You've clearly had great success, what would you say are the main things you've learnt along the way?
One of the key successes of this work has been the dedication, drive and ambition of all those involved in the programme. The collaborative working across the organisations has proven to be extremely effective in transforming services for the local respiratory population and has been integral to its success.
Dedicated time from those working in finance and business intelligence has been integral to this work to support in understanding the local landscape along with determining outcomes moving forwards. Close team working with medicines management and clinical quality, procurement advice has been vital.
The leadership from both commissioners and clinicians to deliver the shared vision has been essential.
Thank you very much Gill, we hope the service continues to go from strength to strength.