ICHT

Cardio-Respiratory Community Service

from1st April 2016

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?

IMPERIAL COMMUNITY CARDIOLOGY

SERVICES

Menu of Services for GPs

• Advice

– GP email advice (cardiologyadvice.imperial@nhs.net respiratoryadvice.imperial@nhs.net) 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?

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

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

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

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

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

• 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

• 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

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

• 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

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”

• What is the most effective way of doing this?

Work closely with Patient involvement

groups