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ICHT
Cardio-Respiratory Community Service
from1st April 2016
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Committed Consultant Leadership
• Direct Consultant Input at every stage
– Consultant email advice
– Consultant reported direct access tests
– Consultants seeing patients in clinic through whole pathway
– Consultant MDTs and supervision of heart failure nurses
– Consultant supervision of rehabilitation
What are we offering?
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IMPERIAL COMMUNITY CARDIOLOGY
SERVICES
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Menu of Services for GPs
• Advice
– GP email advice ([email protected] [email protected]) Answered within 24 hours
– GP phone line
• Direct access tests only
– Echo, 24 hour ECG, 24 hour BP, spirometry, reversibility testing
– Consultant report and interpretation
• Consultant clinical opinion
– Packaged non-invasive work up prior to consultation
– Specialist nurse lead disease optimisation clinics (heart failure, asthma, copd,)
– Physiotherapist input for airway clearance in Bronchiectasis
What are we offering?
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What are we offering?
Efficient pathways for patients Fewer routine follow up appointments needed Paperless systems Better communications Excellent patient and GP feedback Evolution of services: learning from experience
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Chronic Disease Management & Rehabilitation
• Community HF and COPD Nursing Teams
– Case management of complex patients
– Patient education
– Titrating up life saving drugs
– Remote monitoring
– In reach into hospitals
• Consultant hands on supervision
• Community MDTs for complex patients
• Consultant led cardiac and pulmonary
rehabilitation
• Oxygen review service
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Community Cardio-Respiratory Team
• Clinically lead
– consultants who have a stake in the long term
• Dedicated Community Cardio-Respiratory Manager
• Dedicated Community Cardio-Respiratory Lead Nurse
• Dedicated Community Cardio-Respiratory IT Team
• Dedicated Community Cardio-Respiratory Admin Team
• Clear lines of Responsibility and Accountability
• Low follow up rates
• Email advice service
• Paperless service - SystmOne Community IT solution
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The Technical Solution • SystmOne used for booking, clinical record and monitoring of service
– Shared record with primary care
– Results of tests attached to SystmOne record
– Messaging within SystmOne
– Access to SystmOne within A+E departments enable “care plan” access and named case manager contact
– Alerts when records accessed by urgent care
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Quality and Governance
• Staff rotate with Imperial secondary / tertiary care cardiology/respiratory service
• Electronic record allow patient flows and trends to be recorded • Consultant review of investigations: 24 hour ECG, 24 hour BP, ECG,
echo, Spirometry, FeNo, Lung function • MDTs for Respiratory/breathless patients • Echo: weekly echo meeting. Review of difficult, interesting cases.
Random review for quality control • Extensive audit programmes with favourable benchmarking versus
national data • All clinical incidents reviewed and investigated in a no-blame culture
to improve systems
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• Weekly breathless clinics for those WITHOUT a diagnosis to prevent ‘pinballing’ of patients from one service to another
• To provide rapid diagnostics in a one stop shop setting (echo/spiro/reversibility testing/ consultant and nurse review)
• Onward pathways to include psychology, dietetics, rehabilitation
• Weekly joint MDTs with cardiologists and respiratory consultants and specialist nurses to ensure joined up working
Cardio-respiratory Breathless Service
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• We will work with CCG educational team to be
guided on the most effective way to deliver
teaching
• Aim to up skill GPs in cardio-respiratory disease
via practice based teaching ‘virtual clinics’
• To commence with AF /Asthma/ drugs in COPD
teaching
Education Programme
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Delivering a Holistic Service Rapid and efficient planned care cardio-respiratory service
Specialist nurses connect with social care and palliative care for patients with chronic diseases
Alert system (via RAPA alerts) and hospital in-reach when chronic disease patients admitted so we can manage /review with in-patient team
Admin team will process urgent calls/referrals immediately and arrange tests and review same day/next day to prevent admission
Specialist nurses will offer remote monitoring and review if patients are deteriorating alongside rapid response teams
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• Patient experience; inform and influence service development
• Access to services
• Service access to hard to reach groups
• Development of staffing
• Patient/Public access to information
• Experience data: collection methods
Patient Engagement
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Patient Engagement
• Use of iTrack
– Electronic feedback station on leaving clinic
– Core Questions and “Friends & Family”
• More detailed annual written surveys
– In 5 languages
– Return by post in SAE
• Review feedback from complaints and
compliments routinely
– Feedback to shape service changes
• Audits of patient discharge
– Follow up calls up to 1 year post discharge
– Effective way of assessing rehabilitation programmes and
“frequent flyers”
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• What is the most effective way of doing this?
Work closely with Patient involvement
groups