Integrated respiratory care what s the best model? Georges Ng Man Kwong Pennine Lung Service
key components outcomes leadership & team future
The optimal model of integrated respiratory care that provides the best and most cost effective outcomes is not clear and may alter depending on local prevalence, resources and need Dr Irem Patel, 2010 London Respiratory Network
www.envhealthatlas.co.uk
EoL PR EoL Bury 7127* I PR Heywood, Middleton Rochdale 8079* PR EoL TROH North Manchester Oldham 4702** 28466 * / ** PR 8558* EoL EoL=end of life PR=pulmonary rehabilitation COPD observed (expected**) Bury 1.8%(4.8%), HMR 2%(4.9%), Oldham 1.8%(5%), Mcr 1.9% (4.7%) )
spirometry not spirometers person disease specific pulmonary rehabilitation Secondary care COPD care bundle early supported discharge P Primary care Community self-management plans end of life care
Oldham Manchester
decision support education self-management clinical information systems system design 1 Wagner et al, Managed Care Quarterly 1999 www.improvingchroniccare.org
Integrated care prevents hospitalisations for exacerbations in COPD patients Assessment Self-management Shared care plan Access to specialist Patients admitted to hospital Joint visit with primary care GP visit 2 Casas et al, ERJ 2006;28:1-8 Education program
Components of care Decision support Self-management Clinical Information Information technology System design Education 2 Casas et al, ERJ 2006;28:1-8
Managing complex respiratory patients in the community Identification of high risk patients Primary care search Specialist & GP joint clinic Personalised care plan 4 Gillett at al, BMJ Open Resp Res 2016;3:e000145
Reduction in exacerbations and GP visits, improved diagnostic accuracy and patient experience Decision support Clinical information System design Education Gillett at al, BMJ Open Resp Res 2016;3:e000145
Services with 2 components had lower risk for unscheduled GP visits & hospital admission shorter length of stay 5 Adams et al, Arch Int Med 2007;167:551-561 [a systematic review]
decision support clinical information systems education selfmanagement system design community resources for training smoking cessation exacerbations long term oxygen End of life care 6 Henderson & Rubin, BMC Health Serv Res 2012;12:193 [Delphi method]
acute care diagnosis & planning exercise & activity home care community & social care medicines management
Prevention and health promotion Identification of lung disease Diagnosis and care planning Pulmonary rehabilitation Medicines management Management of stable disease Management of unstable disease Home care Acute care Integrated community and social care End stage lung disease Palliative care
Activity Outcome Impact key performance indicators quality & information
Activity Outcome Impact clinical outcomes patient related outcomes improvement & efficiency
Activity Outcome Impact?
Activity Outcome Impact
Activity Outcome Impact
Activity Outcome Impact
Activity Outcome Impact better care better health reduced costs The Triple Aim 8 Berwick et al, Health Affairs 2008;27:759-769 www.ihi.org
hospital utilisation adherence to guidelines patient satisfaction costs, mortality, quality of life culture, governance, financial structure 15 Martinez-Gonzalez et al, Int J Quality in Healthcare 2014:561-570 [meta-review]
remove boundaries challenge behaviours and attitudes share knowledge lead through innovation collaborate with providers and commissioners 10 Teams without Walls: The value of medical innovation and leadership 2008
Quality improvement in advanced COPD specialist outreach acute with community partnerships community driven integrated specialist expertise into primary care 11 Verma et al, Chronic Respiratory Disease 2017;15:5-18 [INSPIRE]
culture change team development sustainability collaboration 11 Verma et al, Chronic Respiratory Disease 2017;15:5-18
Admission per 100 registered population 5 21 29 34 38 Practice rank Practice List size COPD prevalence COPD admissions COPD register COPD admissions per 1000 patients 5 21 29 34 38 A 10306 2.6% 31 268 11.6 B 17008 1.7% 51 293 17.4 C 4017 2.0% 16 82 19.5 D 2447 3.1% 18 77 23.4 E 6234 1.5% 37 93 39.8
12 Gruen at al, Cochrane Database Syst Rev 2004;4:CDO3798 13 D Ancona et al, Thorax 2014;69:A90 14 Cornwallis et al, Thorax 2017;72:A239
16 BTS Position Statement; role of Respiratory Specialist in provision of IC & LTC 201
Digital future information data 17 Reem Kayyali et al. BMJ Open 2016;6:e11657
acute care diagnosis & planning exercise & activity home care community & social care medicines management
sustainability better care better health reduced costs
18 Marmot M, pub Bloomsbury 2015