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 qual...
National Advisory Group for Respiratory MCNsRemit: Agree priorities and identify a work programme for each year Act as a...
National Advisory Group for Respiratory MCNsScope: Areas covered will include respiratory health and the prevention, trea...
COPD Population Model                     Hospital at                     Home                                            ...
NHS Lothian Respiratory MCN COPD Scottish Enhanced Service Programme:    Community Rehabilitation & Post Exacerbation   ...
NHS Lothian Respiratory MCN Self-management plans    COPD    Paediatric Asthma    Adult Asthma Asthma & COPD Electron...
NHS Lothian Respiratory MCN   Electronic Sleep Apnoea referrals   Bronchiectasis Guidelines & Patient Website (SHOW)   ...
NHS Fife Respiratory MCN Scottish Enhanced Service Programme: COPD  Rehabilitation & Anticipatory Care    COPD Action / ...
NHS Western Isles Respiratory MCN Well North ~ COPD eClinical Referral Guidelines    COPD    Asthma    Spirometry   ...
NHS Western Isles Respiratory MCN Education & Training    16 Community & Primary Care Nurses completed Warwick     Diplo...
NHS Forth Valley Respiratory MCN Case Finding within Smoking cessation Clinics, Keep Well,  Well Man & Prison Service CO...
NHS Greater Glasgow & Clyde Respiratory MCN An Integrated Prevention Framework    Quantitative Focus on Risk Factors   ...
NHS Greater Glasgow & Clyde Respiratory MCN Pulmonary Rehabilitation with integrated self-management  plans Early Suppor...
NHS Greater Glasgow & Clyde Respiratory MCN COPD Local Enhanced Service    Practice Nurse training    Smoking cessation...
NHS Highland Respiratory MCN Extended Community Care Team    MDT: Primary, Community & Secondary Care    Focus on Inpat...
NHS Highland Respiratory MCN LES: Anticipatory Care    Patient Alert: completed in PC with patient & family    Vulnerab...
CHP Name (All) Type EMERG New Admission? New Admission Died During Analysis Period No Match to Sparra Control (All)       ...
NHS Grampian Respiratory MCN Staywell (Peterhead)    Patient Education & Monitoring Software    Anticipatory Care Plans...
NHS Grampian Respiratory MCN Phase I Outcome Results (Peterhead) ↓Admissions ↓ LoS (PR & ACP) ↑Admissions ↓LoS (PR no A...
NHS Dumfries & Galloway Respiratory MCNCommunity Respiratory Warning System (CREWS) Mainstream CREWS Nurse Led Service ...
NHS Dumfries & Galloway Respiratory MCNCREWS Prospective Observational Study: Primary Aim:    Evaluate effect on hospita...
CREWS Equipment
Score                  0                         1                               2                          3             ...
NHS Lanarkshire Respiratory MCN COPD Whole System Service    Outreach Spirometry    Self-management & Pulmonary Rehabil...
Evaluation Outcomes:   Patients Discharges via RHSS 26 to 30%   Avg RHSS LoS 3 to 6 Days ~ ↓2 Days   Average non-RHSS L...
COPD Telehealthcare Project                                                                        Outcomes Data for all 4...
Outcome Measures:          Outcome                  Median        p-valueHospital Admissions                1 vs. 0       ...
Two Sides of the Same Coin:Stakeholder                Corporate ObjectivesObjectivesOutreach Spirometry        HEAT: H6, E...
Conclusion: Admission Avoidance Strategies:   Anticipatory Care Planning    Start Early / Identify Patients @ Risk    ...
Questions
Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach
Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach
Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach
Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach
Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach
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Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach

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  • Respiratory Health Community of Practice: www.knowledge.scot.nhs.uk/respiratory.aspx
  • The Population model shows how a Whole System approach addresses the needs of the patients at each stage of disease severity. Using the concept of “one size does not fit all” different levels off education, self-care, self-management, physical activity and delivery of care have been designed to provide a more variable approach that will hopefully fit the needs of a wider spectrum of patients.
  • Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach

    1. 1. Maureen CarrollChair, National Advisory Group for Respiratory MCNs ANTICIPATORY CARE STRATEGIES
    2. 2. 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 ScotlandReporting 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
    3. 3. 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
    4. 4. 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 wayMembership: 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
    5. 5. COPD Population Model Hospital at Home Level 3 Complex co-morbidity Pr of 3 – 5% Pulmonary es sio Rehabilitation na Level 2 lC Poorly controlled single ar e disease 15 – 20% Self- Se management & lf Ca Self-care re Level 1 Spirometry Well controlled (70-80% of LTC Case population) FindingAwareness Population Wide Prevention, Health Improvement &Raising Health Promotion
    6. 6. 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
    7. 7. NHS Lothian Respiratory MCN Self-management plans  COPD  Paediatric Asthma  Adult Asthma Asthma & COPD Electronic GP Reminders emphasising:  Self-management Plans  COPD Rehabilitation  Post-exacerbation follow-up  Annual Review  Asthma ACT
    8. 8. 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 2010  Admissions stable  Bed Days stable
    9. 9. NHS Fife Respiratory MCN Scottish Enhanced Service Programme: COPD Rehabilitation & Anticipatory Care  COPD Action / Self-management Plan  2010/2011 47 GP Practices participated  2011/2012 52 GP Practices participated EMIS / VISION COPD & Asthma Patient Annual Review Templates  incorporate ‘Asthma/COPD Self-management given’ field & electronic link to the plan Asthma Patient Focus Groups to inform review of pathways
    10. 10. NHS Western Isles Respiratory MCN Well North ~ COPD eClinical Referral Guidelines  COPD  Asthma  Spirometry  Pulmonary Rehabilitation  www.wihb.scot.nhs.uk/sharedguidelines/index.html Sleep Apnoea  4 Community Staff trained in assessment  Local service provided to 40 patients
    11. 11. 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
    12. 12. NHS Forth Valley Respiratory MCN Case Finding within Smoking cessation Clinics, Keep Well, Well Man & Prison Service COPD Awareness Campaigns Self-management Plans  Asthma  COPD COPD Hand Held Record  Antibiotics & Steroids via PGD COPD Telehealth Pilot Alert to Asthma Campaign in partnership with Local Authorities Education Department
    13. 13. NHS Greater Glasgow & Clyde Respiratory MCN An Integrated Prevention Framework  Quantitative Focus on Risk Factors  Integrated Spectrum of Primary, Secondary & Tertiary Prevention to reduce Unplanned Healthcare  Prioritisation of Intervention Respiratory Disease:  Multiple Brief Intervention: Smoking Cessation  Asthma Guideline & Self-management Plans  COPD Guideline & Self-management Plans
    14. 14. 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 years  Stable readmission rates COPD Home Care Project:  Exacerbation of COPD – patients supported at home by GP & RCNS  Supportive Palliative Care , including Anticipatory care Plans
    15. 15. NHS Greater Glasgow & Clyde Respiratory MCN COPD Local Enhanced Service  Practice Nurse training  Smoking cessation advice & referral process Asthma Care Plans Community Pharmacy  COPD Training  COPD Medication Review  Respiratory MCN Prescribing Group established to oversee use of respiratory medications Patient Pathway – all common conditions developed
    16. 16. NHS Highland Respiratory MCN Extended Community Care Team  MDT: Primary, Community & Secondary Care  Focus on Inpatient / Recently Discharged / High Risk Individuals  Direct Spot Purchase of Home Care Products  Local Care Home Beds (2) Outcomes:  ↓ LoS by 2.6 to 3 Days  ↓Bed Occupancy by 19 to 25%  No Change to Admissions
    17. 17. NHS Highland Respiratory MCN LES: Anticipatory Care  Patient Alert: completed in PC with patient & family  Vulnerable Patients List SPARRA Data & Local Knowledge 1% most vulnerable at risk of admission Care Home Patients Outcomes:  5,329 ACPAs developed across NHS Highland  ↓ 29% New Admissions  ↓ 47% Bed Occupancy
    18. 18. CHP Name (All) Type EMERG New Admission? New Admission Died During Analysis Period No Match to Sparra Control (All) Comparison of Emergency Inpatient/Daycase New Admissions Before and After ACPAs Count of New Admission? 700 600 500 Type of Hospital New Admissions 400 New Craigs RGH 300 Raigmore Community 200 100 - Before After Before After Before After Before After Before After Before After Before Before After Before After Badenoch & Caithness East Sutherland Inverness Lochaber Nairn & ArdersierNorth West Ross & Cromarty Skye & Lochalsh Strathspey Sutherland Locality Name Before or After
    19. 19. NHS Grampian Respiratory MCN Staywell (Peterhead)  Patient Education & Monitoring Software  Anticipatory Care Plans  OOH Notifications  Medicines Management  NIV (when indicated)  Hospital @ Home / Assisted Discharge Community Bases PR (Aberdeenshire)
    20. 20. 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)
    21. 21. NHS Dumfries & Galloway Respiratory MCNCommunity Respiratory Warning System (CREWS) Mainstream CREWS Nurse Led Service Direct Contact with RNS Community Nurse Involvement Home Medication Packs (partial implementation)
    22. 22. NHS Dumfries & Galloway Respiratory MCNCREWS 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 Days  Reduction in Home Exacerbations  Reduction in Urgent GP Calls  Reduction in Associated Primary Care Costs  Patient & Carer Satisfaction
    23. 23. CREWS Equipment
    24. 24. Score 0 1 2 3 4 Total Oxygen 93% or above 91-92% with air or oxygen 88- 90% with air/oxygen 80-87% with oxygen Less than 80% with Saturation % with air /oxygen oxygen Pulse rate Less than 90 90-100 101-110 111-129 More than 130 Temperature 35-36.9 37-37.5 37.6-38 >38°C with paracetamol >38°C with antibiotic and antibiotic for 24hrs for 3 days Cough No cough/no Increased cough but no Increased cough with Frequent coughing Severe cough /unable change in cough sputum sputum with sputum 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 None Mild – in feet and ankles Moderate- in calves as Severe – up to knee level Very severe swelling only well as feet above knees Shortness of Not breathless/ Short of breath when Walking slower than on Stops for breath after Too breathless to breath/MRC except on hurrying of walking up level ground because of walking about 100 m or leave the house, or score strenuous slight hill breathlessness, or stop after a few minutes on breathless when exercise for breath when walking level ground level dressing or dressing at own pace Daily Activities Fully Cannot carry out heavy Up and about more than In bed / sitting in chair for In bed or a chair all active/Usual physical work, but can do half the day; can look more than half the day; the time and need a activity when anything else after yourself, but not need some help in lot of looking after well well enough to work looking after yourself TOTAL Usual Score when Well = Score when Unwell: Action: Contact Number for Respiratory Nurse if 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 Adapted from Respicard ®Copyright (c) 2010 Phyllis Murphie and Helen Coles of Dumfries and Galloway Health Board
    25. 25. NHS Lanarkshire Respiratory MCN COPD Whole System Service  Outreach Spirometry  Self-management & Pulmonary Rehabilitation  Respiratory Home Support Service Respiratory ESD LTOT Supportive & Palliative Care  COPD Telehealthcare Pilot Asthma Self-management Plans (Paeds & Adult) Asthma Transitional Care Pathway COPD Action Plan
    26. 26. 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 10  28 Days: 4 to 9 / 6 to 7  90 Days: 11 to 20 / 14 to 17
    27. 27. COPD Telehealthcare Project Outcomes Data for all 4 GP Practices 160 140 GP Audit 01/04/07 - 31/03/08Nos based on a total of 38 patients 120 100 80 Project period from 15/09/08- 60 25/01/2010 (incorporates one yea 40 of data per practice) 20 0 its Vis ce its es s its ion an Vi s nc me vi s s nd ss a on ery nd Ho e mi er y pti Att e rg Ad Att cr i rg Su E su res al A& H GP it OO GP ep sp Ho n n olo No nis ed Pr
    28. 28. Outcome Measures: Outcome Median p-valueHospital Admissions 1 vs. 0 <0.001*Home Medication 0 vs. 2 <0.001*(Antibiotics/Steroids)GP Visits 3 vs. 1 0.23A&E Visits 0 vs. 0 0.14*Statistically significant
    29. 29. Two Sides of the Same Coin:Stakeholder Corporate ObjectivesObjectivesOutreach Spirometry HEAT: H6, E4, E5, E6, E7, A10, T10 LTC: Anticipatory Care Patient ExperienceSelf-management & HEAT: H6, E5, E6, E7, A10, T6, T8, T10 LTC: Self-managementPulmonary Rehabilitation Patient ExperienceRespiratory Home Support HEAT: H6, E4, E5, E6, T6, T8, T10, T12 LTC: Self-management, Anticipatory Care,Service Care Management Patient ExperienceCOPD Telehealthcare HEAT: H6, E5, E6, T6, T8, T10, T12 LTC: Self-management, Anticipatory Care, Care Management Patient Experience
    30. 30. 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
    31. 31. Questions
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