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Knowlsey Community Respiratory Service - part 2

Tuesday, December 11, 2018

Dr Dennis Wat, Consultant Chest Physician, tells us more detail about the Knowsley Community Respiratory Service which consists of:

 

  • a diagnostic service,
  • a consultant-led MDT clinic,
  • an oxygen service,
  • counselling,
  • early supported discharge,
  • a rapid response service,
  • pulmonary rehabilitation and chest physiotherapy, and
  • an admin hub.

You can read part 1 of Dr Dennis Wat's interview with Respiratory Futures here.

Welcome back to Respiratory Futures Dr Dennis Wat. You have been committed to the principle of integrated care for a number of years now and you are part of a very successful service in Knowsley, please can you remind us how this service started?

We have been the provider of the community COPD service in partnership with Knowsley Clinical Commissioning Group since 2011.

The service was developed for Knowsley CCG to address marked health inequalities exemplified by a local prevalence of COPD of 3.2% (5053 patients) which is greater than double the national prevalence.

Funding is clearly an important aspect of any service. How is your integrated care service funded?

The service was commissioned by Knowsley CCG as part of a drive to reduce avoidable COPD admissions. Following the success of the community COPD service, the service was expanded by the CCG to cover additional respiratory conditions (see below) to further reduce admissions.

Which patients can access the service?

From the outset of the service, all COPD patients registered under a Knowsley GP were eligible to utilise the service. Following the service expansion, from June 2016, the service was extended to patients with community acquired pneumonia and bronchiectasis.

From November 2016, patients with other respiratory conditions have also been able to access the service. Now, patients with a variety of respiratory conditions will be diagnosed and managed in the community clinics. These conditions include (but are not exclusive to):

  • COPD,
  • Pneumonia,
  • Asthma,
  • Bronchiectasis,
  • Obstructive Sleep Apnoea,
  • Cough, and
  • Lung fibrosis.

How is the service staffed?

Our staff is made up of:

  • 1 Service Line Manager/Lead nurse
  • 9 Consultant Chest Physicians
  • 2 Respiratory matrons
  • 15 community respiratory nurse specialists
  • 3 Physiotherapists
  • 2 Exercise physiologists
  • 2 Health care assistants
  • 1 Psychologist and 1 Counsellor
  • Respiratory Physiologist
  • Admin and secretaries

In addition we work closely, and have regular meetings, with the following services, teams and healthcare professionals:

  • Palliative care nurse from Community Respiratory Disease Service
  • Hospice/Community Palliative Care team
  • Community matrons
  • District Nurse
  • Community IV team
  • Representative from social services
  • Smoking cessation service
  • Primary Care Clinician
  • Northwest Ambulance Service

Remind us, what key services are provided?

The Knowsley community respiratory service has the following components:

It would be really helpful if you could tell us a little more about the key aspects of the service.

Diagnostic service:

The spirometry service within the Community Respiratory Disease Service comprises of diagnostic and annual review components. The quality assured diagnostic component can aid diagnosis and refute of several respiratory conditions. For those patients who are already on the GP COPD QOF register and those who are on the existing community COPD database, an automatic call and recall system which is already in place continues to be utilised to provide annual spirometry and review services to these patients.

The spirometry service also welcomes referrals from external providers to undertake spirometry testing on patients with known respiratory diseases. The test may allow monitoring of disease progression and aid management plan.

Fractional concentration of exhaled nitric oxide (FENO) test is used to aid the diagnosis and monitoring of asthma patients.

Consultant-led MDT Clinics:

The following patients are referred into the service for assessment by the consultant at the MDT clinic:

  • Patients with stable symptoms who are in the community
    • with a known respiratory diagnosis
    • with a suspected respiratory disease
  • Patients with an acute respiratory illness who are in the community
  • Patients being recently discharged from hospital

Services within the Consultant-led MDT clinics include:

  • Diagnostic physiological measurements (spirometry with reversibility)
  • Annual spirometry and review for patients with COPD
  • Clinical assessment by a specialist to formulate a diagnosis
  • Initiation and optimisation of treatment
  • Development of personalised patient management plans
  • Ongoing long term respiratory follow up
  • Patient and carer education
  • Home Oxygen Service - Assessment and Review (incorporating home visits for patients newly commenced on oxygen)

The Consultant led MDT clinics take place across Knowsley at times suiting patients, at convenient locations close to patients’ homes by utilising the available primary care resource centres. The clinics allow patient access to respiratory care for the purposes of assessment, diagnosis and on-going respiratory management. The clinics reduce routine out-patient attendances at the hospital, providing an excellent, specialist, patient and family centred care in a friendly environment. Family members and carers are invited to accompany patients for all clinic visits to discuss any issues related to their care.

The staffing structure for MDT clinics is as follows:

Since December 2017, we have set up a joint clinic with the local drug addiction service as it is well known that this patient group engages poorly with non-emergency medical services. However, they tend to engage well with the drug services. Aligning respiratory services with the local drug service proved popular and feasible, the incidence of chronic respiratory disease was high in this group.  The proportion of patients with underlying emphysema was high, suggesting screening programmes just focused on spirometry alone may miss a significant number of patients suffering from COPD.

Home Oxygen Service - Assessment and Review:

The oxygen service referral process is as follows:

Pulmonary rehabilitation, respiratory physiotherapy and breathlessness support:

Inspire Programme “Breath Better, Live Better”

The Inspire Programme is of flexible length, and patient centred to focus on their individual goals/needs.  The programme is happy to accept emergency referrals for chest clearance and this is one of the features of the rapid response team. Referrals from various sources for pulmonary rehabilitation is accepted in a timely fashion. 

The pulmonary rehabilitation referral pathway is as follows:

Early Supported Discharge (ESD):

Respiratory specialist nurses are present 7 days per week within our nearby acute trusts to help pro-actively identify patients being admitted to hospital with respiratory diseases.  The patients are reviewed within 13 hours of admission and then followed throughout their inpatient stay.  Once patients are identified as suitable for the Early Supported Discharge scheme, they will be assessed and referred to the community respiratory service. Patients will be seen at home within 24 hours of discharge and receive care for up to 14 days. 

During ESD, patients will be visited in their usual place of care and the following services will also be provided:

  • Rescue antibiotics, steroids, nebulised medications via PGDs and emergency oxygen.
  • An offer of smoking cessation advice and referral for support.
  • A referral and assessment for pulmonary rehabilitation.
  • Inhaler technique review and optimisation of inhaled therapies.
  • A written self-management plan including the use of rescue medications and the phone number of our Rapid Response team whom they should call if they are unwell with symptoms of a flare up of their respiratory condition.
  • Oxygen saturations monitor and if oxygen saturations are <92% on air, referral will be made to the oxygen assessment clinic once clinical stability is achieved.
  • Arrangement of annual spirometry for COPD patients.
  • Referral to Consultant-led MDT clinic for assessment.

Rapid Response service:

The aim of the rapid response service is to provide a safe, efficient and effective approach for selected patients who have exacerbations of their lung conditions. Patients (or their carers) who are already on the Community Respiratory Disease register, can self-refer to the Rapid Response Team using either the Freephone or STD number.  The telephone clinical triage and health care practitioner advice line will operate 24 hours per day, 7 days per week and 365 days per year. This telephone service is operated by a respiratory nurse specialist or physiotherapist who will have access to the patient’s clinical record via EMIS, so that accurate and safe management will be offered to patients.

We have worked closely with walk-in centres, out of hours GP, unplanned care direct and the North West Ambulance Service to divert appropriate respiratory to our rapid response service to mitigate avoidable admissions. The collaboration with these services were made more seamless by have information sharing agreement in place and allow safer service provision.

For those patients who are deemed safe to be managed at home, ongoing support will be provided over the first few days until recovery from the acute episode either by home visits, telephone support or remote telehealth monitoring.

The non-medical prescribers within the rapid response team can provide acute treatment to the patients without having to contact the GPs; this will improve efficiencies within the service and workload placed upon the primary care team.

Psychotherapy/Counsellor:

The Counsellor has vast experience in COPD and the effects on patients and their families/carers, who can offer an integrated approach to the patient’s therapy and work on an individual basis when determining which style of intervention will be most useful to the patient. The patient can also self-refer back to the service in the future as often as the disease progresses as the psychological problems can change and return. Part of the Counsellor’s role is to educate the patient about the psychological effect especially about anxiety and panic attacks. This is often through describing the physiology of the body’s response to stress and teaching coping strategies as well as in some cases suggesting pharmacological help. The other features of the psychological support of the service include:

  • Patients with a confirmed diagnosis of respiratory disease will be screened for anxiety and depression using a HAD scale and then offered an assessment with the Counsellor
  • Offer support to patients in changing their behaviours and engaging with lifestyle modification advice
  • Offer in reach into secondary care to aid discharge in patients with severe anxiety related to their respiratory illness

Symptom management/Palliative care:

 Referrals are accepted via the Administration Hub that operates 365 days per year from health care professionals including GPs, practice nurses, community matrons, nurse clinicians, health care support workers, secondary care providers, social workers, CPNs, community physiotherapists, standard referral templates, referral letters, safe haven fax and secured NHS email. Also, a large proportion of patients will be identified as potentially being in their last 12 months of life by the community respiratory team.

Once patients have been identified as approaching their last 12 months of life, with their consent they are added to a palliative care register and this information is shared with their primary care team.  Patients on the palliative care register is case-managed by members of the respiratory team to ensure that they receive optimal care.

Communication with hospice and community palliative care services takes place at a monthly MDT meeting to discuss challenging cases and ensure optimal management whilst reducing duplication in workload. The followings are invited to attend the MDT:

  • Palliative care nurse from Community Respiratory Disease Service
  • Hospice/Community Palliative Care team
  • Community matrons
  • District Nurse
  • Representative from social services
  • Primary Care Clinician
  • Other interested stakeholders (e.g. ambulance service)

We work with patients' primary care teams effectively by attending primary care team ‘GSF’ meetings to discuss with GPs and district nurses. Psychological support is offered to patients, their families and their carers where necessary. Bereavement counselling is offered to patient’s families and carers. 

Education:

The service works closely and proactively with the GP educational lead in order to provide education to the primary care regarding the optimal management of a variety of respiratory conditions in the primary care setting. This enabled an increase uptake of the service. Likewise, similar educational programmes regarding respiratory disease are provided to practice nurses/nurse clinicians and community matron so as to foster a close and seamless work relationship to provide a consistent and high quality of care for the population of Knowsley.

Education, including the following, are provided to patients and carers:

  • details about the conditions the patients suffer from,
  • causes of the conditions,
  • management options for the conditions, and
  • how to live with the conditions including physical activity and dietetic advice.

Patients will be encouraged to have patient passports to ensure they receive the appropriate level of care for their condition

COPD flare up management plan

 

Primary Care Education:

We are committed to facilitating the training curriculum for local GPs and primary care teams and are keen to support re-validation in Primary Care. We have provided a number of GPs’, practice nurses’, community matrons’ and local pharmacists’ education meetings and have received exemplary feedback. We work closely with the education and respiratory leads in Knowsley CCG continue to provide regular educational meetings. We also use these opportunities to discuss referral pathways and services, to improve the quality, efficiency and effectiveness of patient care.

 

Are there any new developments to the service on the horizon?

Following the successful attainment of patient’s information sharing agreement between our community service and primary care, we are in the process of phase implementing EMIS as an IT platform for our community service. All GP practices within Knowsley utilise EMIS software. The benefits of this IT platform include the following:

  • Allowing the community team to have access to patient investigations results (pathology, microbiology, etc) that were carried out at the primary care level.
  • Allowing community service and primary care to record, access and share vital information.
  • Streamlining the communication between primary and community services and has the cost saving potential by reducing admin staff and time.
  • Taking control of unscheduled care by easily tracking and managing care delivery.
  • Saving time, reducing costs and, in line with the NHS Five Year Forward View, achieving a paperless service by 2020.

 

You can see details of the Knowsley Community Respiratory Service, and other integrated care services in Cheshire and Merseyside on the integrated futures map here.