parallel session 1.6.1 managed clinical networks and quality improvement: a distinctively scottish...
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Maureen CarrollChair, National Advisory Group for Respiratory MCNs
ANTICIPATORY CARE STRATEGIES
National Advisory Group for Respiratory MCNs‘The Respiratory Club’
Aims: To foster respiratory health To improve the quality of care for patients with respiratory disease throughout
Scotland To encourage the implementation of good practice through local Managed Clinical
Networks (MCNs) sharing information, knowledge and being guided by the Core Principles laid out in HDL(2007)21 – Strengthening the Role of Managed Clinical Networks in Scotland
Reporting Arrangements: The NAG is in many ways similar to a club in that it survives through the desire of the
members to work together to achieve shared aims in a consensual way, but with no compulsion to participate. The reporting arrangements are, therefore, to the NHS Boards through the local MCN arrangements, and to the SGHD through the Planning & Quality Division
National Advisory Group for Respiratory MCNsRemit: Agree priorities and identify a work programme for each year Act as an advisory group on respiratory issues to the Scottish Government Health Directorates (SGHD) Work with Healthcare Improvement Scotland to agree the current core evidence base to recommend to MCNs for
implementation Contribute to national initiatives such as the development of standards, guidelines and guidance in both practice
and education Support the development of a sustainable process for monitoring the delivery of services to agreed standards Work in partnership with Voluntary Organisations; Partnership Agencies, NHS Organisations and Scottish
Government Health Directorates to take forward national initiatives and service design / redesign in accordance with respiratory standards and guidance
Share information about good evidence based practice and the different models of delivering respiratory services Agree and maintain a shared core evidence base for respiratory disease relevant to Scotland Encourage development of a shared information system or systems to allow audit and comparison of the
outcomes of care and to support decision making by both clinical and managerial professionals Support the development and implementation of Scottish Core Competencies Support MCNs to:
Strive for an equitable distribution of services and promote patient access to agreed standards of care across Scotland in order to address health inequalities
Develop the education and training of patients, carers and staff to support identified evidence based practice
Increase the multi-disciplinary approach to respiratory health and the care of respiratory disease
National Advisory Group for Respiratory MCNsScope: Areas covered will include respiratory health and the prevention, treatment and long term care of
all respiratory disease only excluding those areas covered by existing MCNs such as cancer and cystic fibrosis
Authority is invested in NHS Boards and the SGHD and therefore the National Advisory Group will require to operate in a consensual way
Membership: Mainland NHS Board areas will have two members drawn from the local MCN usually comprising
clinical and managerial responsibilities Island NHS Board areas will have one member drawn from the local MCN usually comprising
clinical and/or managerial responsibilities British Lung Foundation, Asthma UK and Chest, Heart & Stroke Scotland each to provide one
member SGHD Planning & Quality Division will provide one member in attendance Scottish Thoracic Society will provide one member in attendance Should any member be unable to attend a meeting deputies will not only be welcomed but
encouraged Patient/Carer input will be obtained through the voluntary sector. However, if specific matters
require in-depth Patient/Carer participation, this will be sought via the local Respiratory MCN and Voluntary Organisation engagement structures
COPD Population Model
Professional CareSelf Care
Hospital at Hospital at Home Home
Pulmonary Pulmonary RehabilitationRehabilitation
SpirometrySpirometry
Level 3Level 3Complex co-morbidity Complex co-morbidity
3 – 5%3 – 5%
Level 2Level 2Poorly controlled single Poorly controlled single disease 15 – 20%disease 15 – 20%
Level 1Level 1Well controlled Well controlled (70-80% of LTC (70-80% of LTC population)population)
Population Wide Prevention, Health Improvement & Health Promotion
Self-Self-management & management & Self-care Self-care
Awareness Awareness RaisingRaising
Case Case FindingFinding
NHS Lothian Respiratory MCN
COPD Scottish Enhanced Service Programme: Community Rehabilitation & Post Exacerbation
Service integrated with hospital service ↑Telecare to deliver Rehabilitation Home Rehabilitation in Edinburgh City 75% Patients with Severe and Very Severe COPD Significant rise in OOH & Palliative Care registration
Anticipatory Care Plans for all LTC
NHS Lothian Respiratory MCN
Self-management plansCOPDPaediatric AsthmaAdult Asthma
Asthma & COPD Electronic GP Reminders emphasising:Self-management PlansCOPD RehabilitationPost-exacerbation follow-upAnnual ReviewAsthma ACT
NHS Lothian Respiratory MCN
Electronic Sleep Apnoea referrals Bronchiectasis Guidelines & Patient Website (SHOW) COPD Awareness & Case Finding COPD Data
↑ Prevalence from 13,000 to 14,000 since 2010Admissions stableBed Days stable
NHS Fife Respiratory MCN
Scottish Enhanced Service Programme: COPD Rehabilitation & Anticipatory Care COPD Action / Self-management Plan2010/2011 47 GP Practices participated 2011/2012 52 GP Practices participated
EMIS / VISION COPD & Asthma Patient Annual Review Templatesincorporate ‘Asthma/COPD Self-management given’
field & electronic link to the plan Asthma Patient Focus Groups to inform review of
pathways
NHS Western Isles Respiratory MCN
Well North ~ COPD eClinical Referral Guidelines
COPDAsthma Spirometry Pulmonary Rehabilitation www.wihb.scot.nhs.uk/sharedguidelines/index.html
Sleep Apnoea4 Community Staff trained in assessment Local service provided to 40 patients
NHS Western Isles Respiratory MCN
Education & Training 16 Community & Primary Care Nurses completed Warwick
Diploma in COPD Management 30 staff received Spirometry Training
Pulmonary Rehabilitation Physiotherapist appointed Respiratory Liaison Nurse hours extended Hub established in WI Hospital Telehealth links to Southern Isles in place Links with Local Authorities Sports Service established with 4
Instructors trained to deliver COPD exercise
NHS Forth Valley Respiratory MCN
Case Finding within Smoking cessation Clinics, Keep Well, Well Man & Prison Service
COPD Awareness Campaigns Self-management Plans
AsthmaCOPD
COPD Hand Held RecordAntibiotics & Steroids via PGD
COPD Telehealth Pilot Alert to Asthma Campaign in partnership with Local Authorities
Education Department
NHS Greater Glasgow & Clyde Respiratory MCN
An Integrated Prevention FrameworkQuantitative Focus on Risk FactorsIntegrated Spectrum of Primary, Secondary & Tertiary
Prevention to reduce Unplanned Healthcare Prioritisation of Intervention
Respiratory Disease:Multiple Brief Intervention: Smoking CessationAsthma Guideline & Self-management PlansCOPD Guideline & Self-management Plans
NHS Greater Glasgow & Clyde Respiratory MCN
Pulmonary Rehabilitation with integrated self-management plans Early Supported Discharge Service
1/3 admissions are discharged early with support of Respiratory Clinical Nurse Specialist (RCNS) Team
↓LoS from Avg 7.6 to 6.0 over past 5 yearsStable readmission rates
COPD Home Care Project:Exacerbation of COPD – patients supported at home by GP
& RCNS Supportive Palliative Care , including Anticipatory care Plans
NHS Greater Glasgow & Clyde Respiratory MCN
COPD Local Enhanced ServicePractice Nurse training Smoking cessation advice & referral process
Asthma Care Plans Community Pharmacy
COPD TrainingCOPD Medication Review Respiratory MCN Prescribing Group established to
oversee use of respiratory medications Patient Pathway – all common conditions developed
NHS Highland Respiratory MCN
Extended Community Care Team MDT: Primary, Community & Secondary CareFocus on Inpatient / Recently Discharged / High Risk
IndividualsDirect Spot Purchase of Home Care ProductsLocal Care Home Beds (2)
Outcomes:↓ LoS by 2.6 to 3 Days↓Bed Occupancy by 19 to 25% No Change to Admissions
NHS Highland Respiratory MCN
LES: Anticipatory Care Patient Alert: completed in PC with patient & familyVulnerable Patients List
SPARRA Data & Local Knowledge1% most vulnerable at risk of admission Care Home Patients
Outcomes: 5,329 ACPAs developed across NHS Highland↓ 29% New Admissions ↓ 47% Bed Occupancy
Comparison of Emergency Inpatient/Daycase New AdmissionsBefore and After ACPAs
-
100
200
300
400
500
600
700
Before After Before After Before After Before After Before After Before After Before Before After Before After
Badenoch &Strathspey
Caithness East Sutherland Inverness Lochaber Nairn & ArdersierNorth WestSutherland
Ross & Cromarty Skye & Lochalsh
New
Adm
issi
ons
New Craigs
RGH
Raigmore
Community
CHP Name (All) Type EMERG New Admission? New Admission Died During Analysis Period No Match to Sparra Control (All)
Count of New Admission?
Locality Name Before or After
Type of Hospital
NHS Grampian Respiratory MCN
Staywell (Peterhead) Patient Education & Monitoring Software Anticipatory Care Plans OOH NotificationsMedicines Management NIV (when indicated)Hospital @ Home / Assisted Discharge
Community Bases PR (Aberdeenshire)
NHS Grampian Respiratory MCN
Phase I Outcome Results (Peterhead) ↓Admissions ↓ LoS (PR & ACP) ↑Admissions ↓LoS (PR no ACP) Phase II Outcome Results (Aberdeenshire) ↓28% GP Consultations ↓50% Admissions ↑27% Antibiotic Prescriptions ↑14% Oral Steroid Prescriptions
(Lower for Longer, 30mg daily for 7-10 Days)
NHS Dumfries & Galloway Respiratory MCN
Community Respiratory Warning System (CREWS) Mainstream CREWS Nurse Led Service Direct Contact with RNS Community Nurse Involvement Home Medication Packs (partial implementation)
NHS Dumfries & Galloway Respiratory MCN
CREWS Prospective Observational Study: Primary Aim:
Evaluate effect on hospital admission rates of > 300 subjects with COPD/Chronic lung disease resulting from the application of a telephone supported /administered CREWS
Secondary Aims:Reductions in Bed DaysReduction in Home ExacerbationsReduction in Urgent GP CallsReduction in Associated Primary Care Costs Patient & Carer Satisfaction
CREWS Equipment
Score 0 1 2 3 4 Total
Oxygen Saturation %
93% or above with air /oxygen
91-92% with air or oxygen 88- 90% with air/oxygen 80-87% with oxygen Less than 80% with oxygen
Pulse rate Less than 90 90-100 101-110 111-129 More than 130Temperature 35-36.9 37-37.5 37.6-38 >38°C with paracetamol
and antibiotic for 24hrs>38°C with antibiotic
for 3 days
Cough No cough/no change in cough
Increased cough but no sputum
Increased cough with sputum
Frequent coughing with sputum
Severe cough /unable to clear sputum
Sputum None Small amount Moderate amount Large amount Very Large
Sputum colour None White Yellow Green Brown /Blood
Wheeze no wheeze Infrequent With significant exertion With moderate exertion While sitting at rest
Ankle/Leg swelling
None Mild – in feet and ankles only
Moderate- in calves as well as feet
Severe – up to knee level Very severeabove knees
Shortness of breath/MRC
score
Not breathless/except on strenuous exercise
Short of breath when hurrying of walking up
slight hill
Walking slower than on level ground because of breathlessness, or stop for breath when walking
at own pace
Stops for breath after walking about 100 m or after a few minutes on
level ground level
Too breathless to leave the house, or
breathless when dressing or dressing
Daily Activities Fully active/Usual activity when
well
Cannot carry out heavy physical work, but can do
anything else
Up and about more than half the day; can look after yourself, but not well enough to work
In bed / sitting in chair for more than half the day;
need some help in looking after yourself
In bed or a chair all the time and need a lot of looking after
TOTAL
Adapted from Respicard ®
Usual Score when Well = Score when Unwell: Action: Contact Number for Respiratory Nurseif CREWS changes by score of 3 or more: Phyllis Murphie – 01387 241860 / Helen Coles- 01387 241835 Normality (score range 0– 11) Mild to Moderate exacerbation (score 12 - 22)- caution- discuss with contact nurse Severe exacerbation (score above 22 alarm zone) – Discuss with your contact Nurse
Copyright (c) 2010 Phyllis Murphie and Helen Coles of Dumfries and Galloway Health Board
NHS Lanarkshire Respiratory MCN COPD Whole System Service
Outreach SpirometrySelf-management & Pulmonary RehabilitationRespiratory Home Support Service
Respiratory ESDLTOTSupportive & Palliative Care
COPD Telehealthcare Pilot Asthma Self-management Plans (Paeds & Adult) Asthma Transitional Care Pathway COPD Action Plan
Evaluation Outcomes:
Patients Discharges via RHSS 26 to 30% Avg RHSS LoS 3 to 6 Days ~ ↓2 Days Average non-RHSS LoS 5 to 11 Days Readmission Rates (%) RHSS / non-RHSS:
14 Days: 5 to 9 / 5 to 1028 Days: 4 to 9 / 6 to 790 Days: 11 to 20 / 14 to 17
COPD Telehealthcare ProjectOutcomes Data for all 4 GP Practices
0
2040
60
80
100120
140
160
No's
bas
ed o
n a
tota
l of 3
8 pa
tient
s GP Audit 01/04/07 - 31/03/08
Project period from 15/09/08-25/01/2010 (incorporates one yearof data per practice)
Outcome Measures:
Outcome Median p-value
Hospital Admissions
1 vs. 0 <0.001*
Home Medication (Antibiotics/Steroids)
0 vs. 2 <0.001*
GP Visits 3 vs. 1 0.23
A&E Visits 0 vs. 0 0.14
*Statistically significant
Two Sides of the Same Coin:
Stakeholder Stakeholder Objectives Objectives
Corporate Corporate Objectives Objectives
Outreach SpirometryOutreach Spirometry HEAT: H6, E4, E5, E6, E7, A10, T10HEAT: H6, E4, E5, E6, E7, A10, T10
LTC: Anticipatory Care LTC: Anticipatory Care
Patient Experience Patient Experience
Self-management & Self-management & Pulmonary RehabilitationPulmonary Rehabilitation
HEAT: H6, E5, E6, E7, A10, T6, T8, T10HEAT: H6, E5, E6, E7, A10, T6, T8, T10
LTC: Self-managementLTC: Self-management
Patient Experience Patient Experience
Respiratory Home Respiratory Home Support ServiceSupport Service
HEAT: H6, E4, E5, E6, T6, T8, T10, T12 HEAT: H6, E4, E5, E6, T6, T8, T10, T12
LTC: Self-management, Anticipatory LTC: Self-management, Anticipatory Care, Care Management Care, Care Management
Patient ExperiencePatient Experience
COPD Telehealthcare COPD Telehealthcare HEAT: H6, E5, E6, T6, T8, T10, T12HEAT: H6, E5, E6, T6, T8, T10, T12
LTC: Self-management, Anticipatory LTC: Self-management, Anticipatory Care, Care Management Care, Care Management
Patient Experience Patient Experience
Conclusion: Admission Avoidance Strategies:
Anticipatory Care Planning Start Early / Identify Patients @ Risk Patient Education / Coaching Patient Self-management & Action Plans Patient Self-Care & Home Medication Packs Telehealthcare Options Supportive & Palliative Care Strategies (ACPs)
Managed Clinical Networks: The Big Picture Whole System Working Quality Ambitions Stakeholder & Corporate Objectives
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