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Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
Breakout 3.3 Pro-active management - Stephen Gaduzo
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Breakout 3.3 Pro-active management - Stephen Gaduzo

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Breakout 3.3 Pro-active management - Stephen Gaduzo …

Breakout 3.3 Pro-active management - Stephen Gaduzo
GP, Stockport
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

Published in: Health & Medicine
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  • 1. Pro-active management Stephen Gaduzo GP, Stockport Plan• Stratification• Structured review• Management of stable disease• Consistent messages• Integrated care 1
  • 2. Stratification When to start treatment? 100 Severe FEV1 (% of predicted) Symptoms 50 Asymptomatic Lung Lung 20 function function normal reduced Mild Axis of progressionAdapted from Sutherland E N Engl J Med 2004; 350: 2689–2697. 2
  • 3. Early diagnosis & treatmentAnnual cost of treatment for COPD patients Mild £98 Moderate £1021 Severe £3944 Very severe £6475Prevention – Listen to your lungs 6 3
  • 4. Identifying those at high risk of admission • Very severe disease (FEV1 <30%) • On LTOT – or need it but don’t yet have it • Older (aged >75yrs) • Reduced mobility / physical activity (MRC) • Co-morbidities (IHD, CHF, diabetes, depression, anxiety) • Previous unscheduled admissions • Frequent admitters - 60% risk of further admission vs. 10% risk in those having first admissionGarcia Americh Thorax 2006 and 2008 EoL COPD Trigger tool Severe (FEV1 <50%) or very severe COPD (FEV1 <30%) Frequent exacerbations ( ≥3 acute exacerbations in the last 12 months especially if associated with hospital admission Need for NIV Unremitting symptoms despite maximal therapy Dependence on oxygen Co-morbidities Consider refer for palliative assessment and addition to GSF registerNHS Salford 2010 4
  • 5. 9 School Nurse TrainingEmployers engaged by Oct 2012 No. of school nursesLancashire FT and partners 113Liverpool Community Health 90Bridgewater 100Stockport 30Tameside and Glossop 22Central and Eastern Cheshire 47Blackpool 25• Local Authority workforce training• CCG asthma master class• Asthma awareness 10 5
  • 6. Structured review 6
  • 7. • How many COPD patients have NO co-morbidity?• How many COPD patients have NO co-morbidity? • 18% 7
  • 8. Most people with any long term condition have multiple conditions in Scotland Elderly patients • Compliance with therapy (self) • MMSE > 24/30 – usual therapy • MMSE 20-23/30 – may manage inhaled therapy • MMSE <20/30 – unable to manage • Symptom recognition • Susceptibility to DeliriumAllen SC et al Age and Ageing 1997 8
  • 9. Patient Perspectives • Under-estimates symptoms • Under-uses of prophylaxis • Tolerates poor symptom control • Has low expectations of therapy • Confused / lacks knowledge of correct drug • Poor adherence • Bargains with self and you, trade-off of symptoms vs. inconvenienceHolgate et al, 2006 BMC Pulmonary medicine 6(suppl 1):S2 Value for money – Cost per QALY Triple therapy LABA/LAMA Pulmonary rehabilitation Stop smoking support with pharmacotherapy Flu vaccination in “at risk” population http://www.impressresp.com/index.php?option=com_docman&Itemid=82 9
  • 10. Pulmonary Rehabilitation • % of COPD population referred? • % drop out rate?Troosters et al ERJ 2010; 19: 24 - 29 Pulmonary Rehabilitation • % of COPD population referred? • 1% • % drop out rate? • 31%Troosters et al ERJ 2010; 19: 24 - 29 10
  • 11. Audits• “Missing millions” – Age >35, smoker or ex, chest inf/Abx/pred L12m• MRC 3 or above – Referred for Pulmonary Rehab?• Triple Rx (ICS, LABA & LAMA) – Had smoking cessation, flu jab, considered for PR?• Exceptions from QOF?• Prevalence of COPD increasing? Management of stable disease 11
  • 12. Outcomes Strategy Respiratory Clinical Pathway TeamRespiratory health & good lung healthEarly accurate diagnosisActive partnership between HCPs and patientsChronic disease managementTailored, evidence-based Rx for the individual Working together to improve respiratory care in the North West Respiratory Clinical Pathway Team Diagnosis Register Education Appropriate treatment Monitor Working together to improve respiratory care in the North West 12
  • 13. Greater Manchester Inhaler Technique Traininghttp://wires.wessexhiecpartnership.org.uk/video-series/inhaler-technique/ 25 Variation & the power of data 13
  • 14. Stockport PCTStockport PCT Smoking Prevalence in LTC Patients April 2010-March 2011 Quit Rate Stockport PCT 47% Greater Manchester Cluster 46% Average NHS NW SHA Average 44% England Average 49% 14
  • 15. Practice(reviews)Exceptionreports 15
  • 16. Self management support – will one size fit all? • To be activated to be effective self managers our patients require a high level of knowledge skills and confidence • Around 40% of patients are likely to need additional support to self manage successfully • By increasing activation step by step our patients can experience small successes and steadily build confidence in their ability to self manageHibbard et al Health Serv Res 2005 Hellmans M abstract PCRJ 2012 16
  • 17. 17
  • 18. Integrated care• Who’s delivering the service?• Who’s commissioning it?• Public Health, Local Authority, Social care?• What about the patients? Complex needs?• Consistent messages• Admission & Discharge bundles Respiratory Clinical Pathway Team Discharge bundle Hopkinson et al Thorax 2011 18
  • 19. Educate and support patients and practice team to reduce risk of admission 19
  • 20. NW Integrated Care Bundle Listening to your voice 20
  • 21. Respiratory Clinical Pathway Team 10 messages your Respiratory patients want to give you: 1. Give me consistent messages 2. Know that my COPD journey started a long time before the diagnosis or before I saw a health professional 3. Realise the time it takes to get my diagnosis right 4. Help me to understand and manage my own care 5. Introduce me and my carer to the right information about my condition 6. Ensure that when in hospital I get to see a specialist 7. Support groups and networks are very important to me. Make me aware of them. 8. Provide access to pulmonary rehabilitation to keep me healthy 9. Show me you care, involve me in my care 10. Boost my confidence in local NHS services that are there to help me Full report available on http://www.inspirationnw.co.uk/inspire/respiratory-listening-event Aims of NWRCPT: • Uniform High Level Standards of Care • Positive Patient Experience • Confident Commissioning of Effective ServicesWorking together to improve respiratory care in the North West Patient Passport • Brings together: • NICE guidance • Outcomes Strategy • Companion document • Quality Standards • Patient Voices Top 10 • Patient held 21
  • 22. Walk the 7 steps to the best COPD careI have COPD:• I have had my diagnosis confirmed by lung function test performed by a qualified person• I feel supported to manage my COPD. I am actively involved in my care and have the opportunity to discuss how I wish to be treated• I have been offered help and support to stop smoking• I know the importance of keeping active and offered the opportunity to improve my activity through exercise and pulmonary rehabilitation if appropriate• I know how and when to take my medicines, and feel able to use my inhalers and other medicines properly• I have a written action plan, rescue medication and know when and how to use them• I see my doctor or nurse routinely at least once a year for review of my lung function, medicines and inhaler technique, breathlessness, activity and oxygen levels, flu vaccination and my action plan 22

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