We worked hard, we secured the funding, but what have we done with the money and how are does respiratory integration actually work in Dorset now?
First, to get an overall sense of direction for everyone involved, we developed a set of aims for respiratory integration. These are:
- Improve the care of respiratory patients across the population.
- Improve diagnosis of respiratory disease.
- Prevent need for secondary care inpatient and outpatient care.
- Provide more cost-effective care.
- Provide care that is more seamless with a better patient experience – bridging primary, community and secondary and across comorbidities.
In Weymouth and Portland (W&P), we are trying to achieve these aims by focusing on a small number of core activities:
We identify and manage high risk patients proactively, especially house bound patients. Primary and secondary care also identify the most difficult respiratory cases, which are then managed by locality-based respiratory nurses. This prevents admissions and facilitates discharge into the community.
We also have a strong focus on staff education and training, and generally working to improve basic COPD and asthma care.
There is always a lot to do, and everyone is constantly busy with their caseload so we had to find a way to help staff find the time to produce the key service delivery changes and longer-term improvements.
Community Respiratory MDT
One of the things we did is to set up a large monthly multidisciplinary team meeting for the secondary care consultant, the lead GP, the locality-based respiratory nurses and HCAs, respiratory physiotherapists from pulmonary rehab service, clinical psychologist, DAIRS (Dorset Adult Integrated Respiratory Service) specialist nurses, GPs, nurse practitioners and practice nurses. We generally hold it in a community hospital or a larger GP surgery.
Anyone can put a patient with a potential respiratory problem on a list to be discussed – normally we can manage up to 10 in 90 minutes.
The aim is to avoid the need for secondary care review, although the outcome sometimes is to request a CT scan or some pulmonary function tests in secondary care. In one year, we have discussed 71 cases, with very few leading to secondary care referral. The outcome of the discussion is written directly into the primary care record and the patient’s GP given a “task” to review the entry and follow our suggestions.
Community Consultant Clinic
Although we have been running secondary care respiratory clinics in community hospitals for very many years, during the last 12 months I have been running them in GP surgeries every other week using the GP records. GPs choose who to refer to the clinic, I see the patient for 30 minutes with ongoing care then generally being with the GP. I take a history and examine the patients, review radiology, blood results and the primary care spirometry results, so that I can give as close a definitive answer as possible as to what is going on and provide advice as to the next steps in diagnosis or management. Often, I can provide reassurance to the patient and GP that there is nothing to worry about; sometimes I pick up complicating non-respiratory conditions
I have seen 93 patients in the last 12 months. Sometimes we discuss patients later at the community MDT. Overall, patients and GPs seem to appreciate the service. One way I would like to develop the clinic would be to run it alongside the practice nurse or a community respiratory nurse with the aim of building their confidence in reviewing more complex patients.
Data
Something that allowed us to integrate our services has been being able to access clinical data of our COPD population. Dorset CCG has been very supportive in enabling us to access and review this data in W&P and many other Dorset PCNs. We can only produce real change if we have access to accurate and timely data so that we can identify the healthcare needs of the population and can assess the effectiveness of our interventions.
The CCG commissioned a private company to support the development of Population Health management processes and they worked closely with us to bring together the data about our COPD population in W&P. Using PowerBI, the CCG then produced a database that captures in real time the clinical characteristics of the COPD population, and can now compare large amounts of information.
Most importantly, it is possible within the one computer screen to examine the clinical characteristics of individual patients (pseudo-anonymised) – which includes smoking status, their MRC score, spirometry, whether they have had a PR referral etc. We are in the process of adding medication use to this.
Thanks to this system, we can now find GP practices that need the most support delivering optimal care, and identify those patients most at risk of future deterioration. It will also be very useful in supporting virtual clinics and group consultations in the future.
Indeed, the greatest challenge, once you gain access to the data, is where do you start?