COPD SERVICE RE-DESIGN

Transcription

1 COPD SERVICE RE-DESIGN Dr Mukesh Singh GP Principal & GPwSI Respiratory Medicine, Horse Fair Practice, Rugeley Clinical Lead LTC & Governing Body member Cannock Chase CCG

2 COPD DRIVERS FOR RE-DESIGN

3 DOH DATA 2011 Clinical COPD - Tip of the Iceberg , Severe Disease* 3 Million SUBCLINICAL COPD

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5 The 2009 General Lifestyle Survey suggests that people with LTCs account for: 50% of all GP appointments 64% of outpatient appointments 70% of all inpatient bed days In total around 70% of the total health care spend in England ( 7 out of every 10) is attributed to caring for people with LTCs This means that 30% of the population accounts for 70% of the NHS spend.

6 Transforming services for COPD Looking back to look forward: Uncoordinated, outdated and over stretched Increase in demand for services An unsustainable system Paternal culture of management Lack of incentives to drive integration Demographic pressures

7 COPD What we did Clinically led service redesign Worked with multiple healthcare professionals and organisations to develop care pathways Joint business case for change Commissioning and delivery of a proactive and integrated community service Whole-system approach to managing patients with COPD

8 COPD What we ve achieved as a health economy CCG 2012 / / / 2015 % difference from 12/13 to 13/14 % difference from 13/14 to 14/15 % difference from 12/13 to 14/15 STAFFORD & SURROUNDS % -15.4% -37.2% The redesign of the COPD pathway and integration of patient management has resulted in a 37.2% reduction in COPD emergency admissions activity over two years Delivery of agreed pathways Patients managed in their homes The success of the reduction is attributed to the multi-disciplinary approach taken to redesign the pathway and the subsequent patient management

9 Primary Care COPD POINTS programme rolled out in primary care which up-skilled GP practices in the use of spirometry to diagnose COPD; Self-management plans for COPD patients, rolled out as part of the innovations group, designed with the community respiratory team; Nurse Clinical Collaborative focusing on COPD. This was attended by Practice nurses, Community Respiratory Team and Respiratory nurses from Mid Staffs FT. The programme covered respiratory assessment, consultation skills, inhalers, medication reviews, self-management, exacerbations and case studies; and Practices also identified patients suitable for Flo Simple telehealth and practices have been given pulse oximeters and thermometers with the aim to empower patients to take more responsibility for their health and wellbeing and seek to improve healthcare use across the different health sectors.

10 Community Care COPD Continued delivery of proactive care, including MDTs with GP practices and pulmonary rehab; Step up of COPD patients went via the community instead of secondary care; Consultant-led outpatient appointments for COPD patients as part of an MDT with the community respiratory nurse specialists; Hot clinics for patients needing a rapid review by a Consultant; and Follow-up appointment from an emergency admission to be had in the community.

11 Secondary Care COPD CQUIN implemented to ensure all patients admitted with COPD were assessed and seen by a consultant in a timely manner (admission bundle); CQUIN implemented to ensure all patients discharged following a COPD emergency admission have been referred to the appropriate follow-on services including follow-up in the community, smoking cessation, pulmonary rehab, community oxygen services (discharge bundle); and Decommissioned COPD outpatients in a secondary care setting and recommissioned in the community via the community respiratory team with Consultant oversight and access.

12 In a single UK primary care cohort

13 18:00hrs COPD patient + Feeling breathless + Confused + No integrated care plan Pharmacy GP 999 A&E Admission No record of care plan, unable to give antibiotics Closed Ambulance visits patient, takes to A&E A&E assess, not happy with patient SATs and decide to admit Antibiotics, more confused, long LOS as SATs don t improve Passing the buck costs big bucks!

14 COPD Thank You