Symptom led services for breathlessness - real life examples

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Symptom-led diagnostic services for breathlessness - real life examples - Wendy Fairhurst, Nurse Partner, Marus Bridge Practice

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Symptom led services for breathlessness - real life examples

  1. 1. 1 Breathlessness Service Wigan Borough CCG Wendy Fairhurst Clinical Director Health First ALW CIC
  2. 2. 2 Health Equity Audits COPD and Heart Failure  Deprivation  Low prevalence  High Admissions  Excessive mortality rates
  3. 3. 3 Why Breathlessness?  Start from symptom based approach rather than disease based approach  Problems with multiple pathology  Problems with diagnosis between cardiac and respiratory causes of breathlessness  Multiple pathologies managed individually not holistically  Limited post-exacerbation follow-up in practice teams – many factors  No detailed personalised management plans
  4. 4. 4 Feedback from Primary Care  Difficulties in the management of patients with multiple pathology  Patients referred to multiple hospital consultants and specialist nurses – inconvenience and confusing for patients – delays in appropriate treatment  Difficulties for some patients in accessing services  Travelling is difficult for this group of breathless patients  There are a high number of follow-up out-patient appointments. These are inconvenient for patients result in a high level of DNAs and are costly
  5. 5. 5 The sort of support that practices need Diagnosing more difficult cases – this includes especially differentiating COPD from asthma and heart failure, but also other conditions. Doing reviews and optimising care on patients with multiple co-morbidities – especially lung disease, heart disease, other vascular disease, diabetes and CKD Doing reviews that go significantly beyond what is required for QoF – especially post exacerbation reviews that analyse causes of exacerbations and devise a plan for preventative measures Identifying high risk patients - Just working with those patients who have been admitted is not enough – most of the year’s admissions were not identified from the lists of previous admissions.
  6. 6. 6 Principles  Integrated working  Early and accurate diagnosis  Service based in Primary Care  Active searching for patients in Primary Care who may be at risk of deterioration  Reviewing difficult cases in Primary by specialist nurses – working alongside practice teams  Giving each patient a self-management plan  Consultant – led clinics in Primary Care – leading to more integrated working  Reviewing patients post-discharge in Primary Care  Developing clinical resources for use within Primary Care
  7. 7. 7 Integrated Working  Patient journey – not clear and equitable across the borough.  Working with other agencies ( Primary Care, Secondary Care, Tier 2)  Need to eliminate duplication
  8. 8. 8 Early and accurate diagnosis  Previously 6 attendances to diagnosis  One stop shop diagnosis of Heart Failure and/or respiratory disease  Working with acute trust and community trust to deliver the service in Primary Care  Screening
  9. 9. 9 Diagnostic Service Pathway
  10. 10. 10 Service based in Primary Care  Support and mentorship. Up- skilling – working alongside staff in Primary Care  Training days  Key role of practice nurses  Mentorship for Gps and practice nurses  Training for practice staff
  11. 11. 11 Active searching for patients who may be at risk of deterioration in Primary Care  Preventing deterioration  Searches  Not waiting for referrals
  12. 12. 12 Assessment in Primary Care by Specialist nurse  Reviewing difficult cases in Primary Care by specialist nurses – working alongside practice teams (helps with up-skilling) – leading to more integrated working  Causes of exacerbations (medication/environmental)  Optimising medication  Patient education and empowerment  Giving each patient a self-management plan  Work with INT project
  13. 13. 13 Developing clinical resources for use within Primary Care  Guidelines for the treatment of exacerbations  Cold weather warnings  Desk top guidance  Long term conditions template
  14. 14. 14 Consultant – led clinics in Primary Care leading to more integrated working  Consultant – works in different practices around the locality on a twice monthly basis  Direct communication with GP’s and practice teams  Mentorship  Care Closer to home  2 week waiting list
  15. 15. 15 Reviewing patients post-discharge in Primary Care  Preventing re-admissions and further exacerbations  Duplication  Working with Acute Trust
  16. 16. 16 Pilot  £121k verified savings ( unscheduled admissions, outpatients and medicines management)18/24 practices.  £180 – estimated - if all 24 practices had been involved  12 month period ( 6 month set up time)  Based on one HRG code – J44 ( COPD admissions)  Initial difficulties in integrating with secondary care ( COPD unit, discharge information)
  17. 17. 17 Diagnosis service results Referred to service New COPD COPD Diagnosis confirmed Treatment optimized New Asthma Asthma diagnosis confirmed treatment optimized Heart Failure Other DNA Under investigatio n 282 88 29 27 13 35 43 12 35
  18. 18. 18 Qualitative results highlights  Improved data input and data collection in Primary Care ( e.g. recording of exacerbations)  Increased prevalence for all 3 diseases ( more accurate diagnosis, picking people up early, early treatment)  Average age of diagnosis reduced  Increased referrals to smoking cessation and pulmonary re-habilitation

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