Post on 16-Jan-2016
COPD Patient and carers
Therapies inc pulm rehab
Intermediate care team
Social Worker
Respiratory Physician
EAW/General Physician
Case manager/Community Matron
GP
Disjointed, duplicationWasted resourcesPoor pathways of carePatient not seen in mostappropriate place
Pathway for COPD patient in Wolverhampton 2011
Tele-medicine
Hospital at home team
Palliative care
Practice nurse
Oxygen service
Ambulance service
A&E
Patient
Integrated care system
Good use of resourcesRobust pathwaysPatient seen at appropriate place
PreventionEarly diagnosisTreatment
CommunicationSelf careEducationPartnerships of careSpecialist reviewConvenient follow upPalliation
Chronic care model
Integrated care pathway
No more silos
• Rainbow feeds into DDG• Commissioner present at monthly meeting• Robust data feed• New Cross manager integral part• Chief operating officer sponsors lung
improvement program
Respiratory In Reach
• 7 day service• Consultant led but multidisciplinary• Potential benefits– Reduced length of stay– Improved diagnosis – coding and triage– Better initial treatment– Improved mortality– Standardised discharge bundle - reduced readmission
rate– Improved patient experience.
HOT Clinic
• Innovative• Consultant delivered daily admission
avoidance clinic• Open access including self referral• Conversion rate currently < 15%• But…….? timely
OPEN ACCESS TO HOT CLINICRespiratory Centre New cross Hospital
(Monday to Friday only)To arrange an urgent appointment.
phone before 11am
If your respiratory condition deterioratesTelephone 01902 695061
MDT
• Fortnightly multidisciplinary meeting• 30 day readmissions discussed + open access
for all members of RAINBOW• Primary care represented through community
matrons• Palliative care consultant and CBT trained
physiotherapist in attendance• Actions plans produced and communicated
Community clinics
• Clinic delivered in heart of high prevalence area (low DNA rate)
• Improved understanding of issues facing GP’s (and vice versa)
• Raises respiratory profile and builds credibility of RAINBOW in general practice
• Facilitates finding the missing millions
Other services in place for COPD patients
• Well established and efficient HOSAR• Hospital at Home• Quality assured spirometry• GPWSI• Pulmonary rehabilitation in 4 areas
04/2011
05/2011
06/2011
07/2011
08/2011
09/2011
10/2011
11/2011
12/2011
01/2012
02/2012
03/2012
04/2012
05/2012
06/2012
07/2012
08/2012
09/2012
10/2012
11/2012
12/2012
01/2013
02/2013
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Length of stay for patients with primary diagnosis of COPD
Mean Spell Duration (Dis)Linear (Mean Spell Duration (Dis))Median Spell Duration (Dis)
Day
s
04/2011
05/2011
06/2011
07/2011
08/2011
09/2011
10/2011
11/2011
12/2011
01/2012
02/2012
03/2012
04/2012
05/2012
06/2012
07/2012
08/2012
09/2012
10/2012
11/2012
12/2012
01/2013
0
10
20
30
40
50
60
30 day readmission rate
month of discharge
Ream
issi
on ra
te (%
)
Hospital Mortality for COPD patients with a primary diagnosis of COPD
7.2
4.4
0
1
2
3
4
5
6
7
8
2011 2012
mo
rta
lity
ra
te (
%)
p = 0.11
Do you think the support and care you receive is joined up and working for you?
0
20
40
60
80
100
120
not at all rarely some of the time almost always
Num
ber