Welcome to Respiratory Futures Dr Justine Hadcroft, Consultant Respiratory Physician, based in Liverpool. We are keen to hear your experience of working in integrated care. How long have been working this area?
I started to work with ACTRITE (Liverpool’s COPD Early supported Discharge Team) when I first started as a respiratory consultant in 2003, though I had had dealings with the team as a Respiratory trainee from its inception. My involvement with the team has grown along the years, in line with its development and expansion.
The Liverpool Community Respiratory Team has a long history. How did the service start?
The Liverpool Community Respiratory Team started in 1998 as ACTRITE (Acute Chest Rapid Intervention Team). It was one of the very first Early Supported Discharge (ESD) schemes in the country.
"[Integrated Care is] a far cry from the traditional hospital-based models of care I had grown up to accept as the norm."
Patients presenting to hospital with an acute exacerbation of COPD would be assessed by a team of specialist nurses for their suitability for home treatment with nebulisers, steroids and antibiotics in an attempt to reduce their length of hospital stay. Acceptance is judged against a pre-defined set of criteria, some physiological, based on prior research publications and guidelines.
What were the quality measures for the service?
The scheme was demonstrated to be safe and effective, resulting in shorter hospital stays with no increased mortality compared with a ‘standard’ admission. This approach has now become so widely adopted that this way of working has become the standard.
The feedback we receive from patients is always positive, and patients are always grateful to be able to avoid a hospital admission and receive treatment in their own homes.
In 2011, the service expanded to include “Hospital at Home”. What does this involve and what benefits did this additional element bring?
When the service only offered an ESD arm, patients had to attend one of the acute hospitals in order to access the service. We felt that we were missing a trick, and wondered if, by altering how we operated, we could help reduce hospital attendances, not simply length of stay. Adding a ‘Hospital at Home’ (HAH) arm in addition to the ESD model meant that patients could access the service without needing to attend hospital at all. This means that, in addition to the ESD function, which reduces length of stay, we also provide an admission prevention service.
Primary Care Practitioners (GPs, practice Nurses, Community Matrons and other HCPs) can refer patients with COPD exacerbations to the team, and an experienced respiratory specialist nurse will visit the patient within 2 hours of referral. They carry out a full clinical and risk assessment with a view to managing the patient with nebulisers, steroids and antibiotics at home, avoiding a hospital admission completely. This has reduced the number of hospital admissions further and enabled local COPD admission figures to remain stable in a climate of increasing admissions elsewhere.
How is your service staffed?
The team comprises mostly band 6 and band 7 advanced practitioners, the vast majority of whom are respiratory specialist nurses. All have a wealth of experience, as well as clinical examination qualifications and many members of the team are nurse prescribers.
“…relatively small changes we make to patients’ management can lead to enormous differences in their quality of life”
One of our band 7 advanced practitioners is a physiotherapist by background, but her scope reaches beyond the traditional physiotherapy role. She provides clinical assessments of patients in the same way as the nurse practitioners do. We also have a band 4 physiotherapy assistant, who is essential to the team.
Our administrative and clerical team member is invaluable, as we discovered recently during a period of maternity leave when we were left without clerical support for a spell!
How does the service operate?
The team operates 7 days a week, from 8am to 8pm, but currently only takes HAH referrals Monday-Friday between 8am and 6pm.
We serve 2 acute trusts - the Royal Liverpool University Hospital and Aintree Hospital - and Liverpool CCG for HAH referrals, and we provide daily input to the exacerbating patients currently on the caseload.
We always have 1 nurse in each of the two hospitals (8am-8pm 7 days a week), one or two ‘responders’ (for HAH referrals) and a number of practitioners carrying out daily visits and telephone reviews of patients whose exacerbations we are currently managing.
We have busy periods and less busy periods, but are never quiet!
The team also provides full COPD optimisation before the patient is discharged from the service, including medicines optimisation, inhaler technique checks, referrals for smoking cessation and Pulmonary Rehabilitation, and liaison with other services (such as Community Matrons, Social Services and Occupational Therapy) in an attempt to improve home support and prevent future hospitalisation.
Your service also has support from 3 respiratory consultants. Can you outline the ways the consultants contribute to the service?
The 3 respiratory consultants (myself, Dr Sally Jones and Dr Paul Walker) are all COPD enthusiasts and provide full time clinical support between them.
There are 4 formal virtual ward rounds a week and telephone support at other times.
Some patients are offered face to face reviews in community clinics with the Community Respiratory Team consultant, often where the diagnosis is uncertain (could it be asthma rather than COPD? Is there bronchiectasis?), symptoms are out of proportion to spirometry or exacerbation rate is high.
We also have a rolling education programme, devised and mostly delivered by the consultant leads, to help expand the team’s COPD knowledge, and provide clinical supervision and on-the-job education in wards rounds etc.
In addition we act as formal supervisors for team members undertaking postgraduate training in areas such as prescribing.
We have provided some ad-hoc practice-based MDTs as well as occasional face to face clinics for our harder to reach population, such as drug users and homeless people with COPD. I certainly found these experiences eye opening, and a far cry from the traditional hospital-based models of care I had grown up to accept as the norm.
What are the key benefits to this approach?
Having the consultants work closely with the team means we all have a good ‘feel’ for people’s strengths and weaknesses. This further enables us to have the confidence in the team’s skills and abilities which is essential for us to work in a virtual way, and also gives the team the clinical support required when they are presented with difficult clinical conundra. It undoubtedly leads to a high conversion rate from ‘referred’ to ‘accepted’ patients.
“Working in new ways enables respiratory expertise to reach greater numbers of patients, even (or perhaps especially) those who would be reluctant to engage with traditional hospital-delivered services”
Thinking back to how you felt when you started out in integrated care, can you remember how it felt to adopt such a novel way of working?
I initially found it a challenge to acclimatise to non-traditional ways of working, such as the virtual, non face-to-face management of patients, and travelling to community clinic venues for non-hospital based clinics. Once I became used to my new working structure, however, I found it incredibly rewarding.
I enjoy working closely with a fantastic group of staff who are knowledgeable, diligent, compassionate and fun. Working in new ways enables respiratory expertise to reach greater numbers of patients, even (or perhaps especially) those who would be reluctant to engage with traditional hospital-delivered services. I have had my eyes opened by having to streamline my expectations of my role as a doctor, especially in community clinics, in line with what the patient wants to get out of the interaction.
What are the main challenges for you and your colleagues?
My biggest bugbear is IT (what else?!) which hinders true integrated working. Our patients may have visited one (or more) of four secondary care trusts for investigations and consultations and the team does not have access to all the clinical systems it needs to glean all of the information that we require to provide care for our patients. We use EMIS as our clinical record, which brings a 5th system into the mix. If I had one wish, it would be for a unified health care record which held all the clinical information about a patient in one place. Patients believe we already have this, and are astounded when they discover that it is not so!
On to a more positive note, what is most rewarding?
Most rewarding of all is seeing how the relatively small changes we make to patients’ management can lead to enormous differences in their quality of life. This is the real reason we all do the jobs that we do, and integrated working can be one of the most satisfying fields to work in for this reason alone.