Belfast ICP Pathways. Dr Dermot Maguire GP Clinical Lead North Belfast ICP

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1 Belfast ICP Pathways Dr Dermot Maguire GP Clinical Lead North Belfast ICP

2 QOF Disease Register & NHAIS Global Sum Findings ICP Area No of practices & patients Frail Elderly -over 65 Resp COPD Diabetes Obesity Stroke AF Smoking - 07&08* North ,003 17,015 3,336 5,370 11,428 2,171 1,702 93,945 South ,301 13,798 1,847 4,173 7,751 2,053 1,652 99,072 East ,319 18,450 1,996 4,877 9,415 2,105 1,639 89,082 West 16 88,359 9,739 2,004 3,307 6,850 1,475 1,146 72,052 TOTAL ,982 59,002 9,183 17,727 35,444 7,804 6, ,151 *Smoking figures No of patients aged 15 years + whose notes record smoking status in the preceding 27 months or who are recorded as current smokers& have had an offer of support & treatment within the previous 27 months

3 No. of patients diagnosed with COPD Belfast 9,183 North 3,336 West 2,004 East 1,996 South 1,847

4 Respiratory Multi Disciplinary Group GP Pharmacist Community Sector Rep Voluntary Sector Rep Consultant Respiratory Physician GPwSI Community Respiratory Nurse Specialist Community Respiratory Physio

5 COPD gaps identified No Out of Hours or weekends services Delivery of diagnosis Case finding / risk stratification as prevention / early detection No pathway for Home Oxygen Service Lack of alternatives to A&E when in crisis Care in hospital not under specialty Community leadership of discharge Inadequate pulmonary rehab.

6 General Practice Community Pharmacy Community & Voluntary Sector Trust Services incl. Community Respiratory Team

7 General Practice Diagnosis & Management (QOF) with support from ICP Respiratory Team Risk Stratification LES incl. Complex Case Review

8 Community Pharmacy Medicines Usage Review Smoking cessation

9 Community & Voluntary Sector Community Support smoking cessation, pulmonary rehab, social support Community Prevention Hub

10 ICP Respiratory Team Early Intervention (extended hours) Admission to Respiratory Unit Supported Discharge ( 7 days) Self Management Pulmonary Rehabilitation Complex Case Review (incl. support for GPs) Psychological Support

11 Palliative Care ICP Respiratory Team General Practice Community Pharmacy Community & Voluntary Sector

12 New COPD Pathway Community support Community & voluntary sector Community prevention: HUB primary & secondary Medicine usage review COPD Patient Risk stratification: LES Community Pharmacy GP Smoking cessation Carer Complex case review ICP Respiratory Team Early intervention Self management Admission to Respiratory Unit Pulmonary rehab Supported discharge Palliative care

13 Anticipated outcomes from new COPD Pathway The proposed new pathway will enable: Earlier detection of undiagnosed COPD with General Practice with a planned coordinated response in primary/community care with individual management plans Enhanced and improved community care through a co-ordinated multi-disciplinary team approach to ensure management of appropriate acute episodes at home 9am- 9pm 7 days a week Emphasis on prevention through better co-ordination of smoking cessation or prevention of smoking programmes Co-ordinated self-management and additional expert patient programmes to improve individual knowledge of COPD for newly diagnosed patients delivered through voluntary/community organisations support Enhanced education for patients who develop psychological issues and require support The admission of patients with an acute COPD episode to hospital with an early inreach resource planned to ensure discharge care bundle The delivery of high quality care at home with access to IV antibiotic treatment for bronchiectasis patients to prevent admission and a home oxygen service with assessed modalities, and Enhanced access to 7 day a week care for patients in receipt of palliative care.

14 Any questions?

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