How to manage… exacerbationsof COPD, asthma &… in hospital Delivering high value integrated care             with KREDIT? ...
Aligning and sharing                      agendas…  Patients present with breathlessness…                       Frightenin...
Right Care for Respiratory FailureGetting the diagnosis rightExacerbation is not the same as pneumonia …Assessing severity...
Value Framework   Health                     Value                          Cost                                  =  Outco...
Right Care for disabling       breathlessness…NOT EASYTo deliver evidence-based support for patientsto stop smoking as tre...
COPD ‘Value’ Pyramid     What we know…. Cost/QALY                                                                Support t...
Effect of smoking on hospital       admissions for COPD and           asthma ….and???For every 1% increase in prevalence o...
Does your hospital have a BTS Quit      Smoking Champion lead? Do your consultants believe that QuitSmoking treatment is h...
Do you have a Quit Smoking service for  patients and staff in the hospital?     Services Offered: •   Outpatient Quit Smok...
Do your hospital decision makers  believe that Quit Smoking treatment is    high value for patients and staff?   Do your c...
Developed by CLARHC                      Hopkinson et al Thorax 2012:67:90-92CQINS to incentivise high value care      201...
One story from a respiratory ward                    50+ year old manSchizophrenia since 20sTobacco addiction: 60 pack-yea...
Care Planning Conference                 why and whoHigh risk of premature deathCurrent care model not workingUnder-treate...
Care Planning Conference:                   what       Person-centred integrated careIdentified care and treatment gaps an...
Person-centred integrated care in hospital       Care planning in out-patients tooRespiratory  Nurse Specialist           ...
A respiratory provider manifestoI am a long term conditions clinicianI care about valueI know how to assess and support pa...
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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick

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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick
NHS London Respiratory Team Lead
Consultant Respiratory Physician, Whittington Health & NHS Islington
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

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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick

  1. 1. How to manage… exacerbationsof COPD, asthma &… in hospital Delivering high value integrated care with KREDIT? Dr Louise Restrick, NHS London Respiratory Team Lead Consultant Respiratory Physician, Whittington Health & NHS Islington Improving OutcomesRight Care Doing the right things and doing things right Right diagnosis including severity Addressing respiratory failure and breathlessness Structured admission & care planning conferences?Value frameworkKREDIT 1
  2. 2. Aligning and sharing agendas… Patients present with breathlessness… Frightening … and disabling Clinicians focus on respiratory failure Frightening !!! Breathlessness and hypoxaemiaPresent to ED pathways of care Respiratory failureCare at home? treatment in hospital Breathless and low oxygen saturation Breathless Hypoxaemia with normal = oxygen Low oxygen saturation saturation Low oxygen saturation but not breathlessBreathlessness 2
  3. 3. Right Care for Respiratory FailureGetting the diagnosis rightExacerbation is not the same as pneumonia …Assessing severity and prognosis …Getting oxygen therapy rightHigh flow O2 increases mortality - from 7% to 11%*Using Non-Invasive Ventilationappropriately11% given NIV had metabolic acidosis…* * Roberts et al NCROP Thorax 2011:66;43-48Right Care for Respiratory Failure …NOT EASY Need clinicians with respiratory diagnostic & treatment knowledge, skills & expertiseAppropriate NIV halves mortality due to respiratory failure in acute exacerbations of COPD from 20% to 10% Getting it right saves lives 3
  4. 4. Value Framework Health Value Cost = Outcomes Health Outcomes Patient defined Cost of delivering bundle of care Outcomes NB Outcomes as defined by patients & their families So we have to ask & listen … Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483What patients & families tell us… ‘I don’t want to die’‘breathlessness is frightening and disabling’ 4
  5. 5. Right Care for disabling breathlessness…NOT EASYTo deliver evidence-based support for patientsto stop smoking as treatment for sick smokers Need long term condition clinicians with behaviour change & motivational interviewing skills To enable patients to benefit from pulmonary rehabilitation KREDIT* Respiratory Teams’ Shared Values … Kindness Respect Empathy Dignity Interest TRUST *Whittington Health, London Respiratory Team and … 5
  6. 6. COPD ‘Value’ Pyramid What we know…. Cost/QALY Support to stop smoking Triple Therapy is key TREATMENT for £35,000- £187,000/QALY sick smokers … LABA Where are the sick £8,000/QALY smokers? Tiotropium £7,000/QALY … in our hospital beds Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £1,000/QALY in “at risk” populationIs current smoking an issue in COPD?2010 ERS Audit 6
  7. 7. Effect of smoking on hospital admissions for COPD and asthma ….and???For every 1% increase in prevalence of smoking in your COPDpopulation there is a 1% increase in COPD admission ratesFor every 1% increase in prevalence of smoking in your asthmapopulation there is a 1% increase in asthma admission rates Emergency respiratory admissions: influence of practice, population and hospital factors Purdey S et al J Health Services Research Policy 2011;16:133-40Changing how we think about smoking ‘Smoking kills, stopping works’ Sir Richard Peto 2012 Tobacco dependenceSick smokers are admitted to hospitals - acute and psychiatric Evidence based quit smoking treatment is the most important treatment for sick smokers: Behaviour change support and quit smoking medication Delivering value in tobacco dependence Top 10 Questions … 7
  8. 8. Does your hospital have a BTS Quit Smoking Champion lead? Do your consultants believe that QuitSmoking treatment is high value for their patients? Does your hospital provide NRT routinely on admission for smokers?Are your hospital staff able, & confidentto, prescribe Quit Smoking medication? 8
  9. 9. Do you have a Quit Smoking service for patients and staff in the hospital? Services Offered: • Outpatient Quit Smoking Clinics: for patients and staff • Inpatient Assessment for Quit Smoking Support • Special Clinics – Pre-operative Assessment & Maternity Support for smokers to quit Do your hospital staff know your Quit Smoking advisors and refer to them? Do your hospital staff routinely offer ‘Very Brief Advice’ to every smoker? Online training module WWW.NCSCT.CO.UK/VBA ‘This training is relevant to anyone who comes into contact with smokers… GPs, practice nurses, hospital doctors, pharmacists & other healthcare professionals. … certificate on successful completion to provide evidence of continuing professional development (CPD).’Do your hospital staff have and use behaviour change skills to support smokers to stop? 9
  10. 10. Do your hospital decision makers believe that Quit Smoking treatment is high value for patients and staff? Do your commissioners believe that Quit Smoking treatment is high value for patients and staff?Increasing the value of care in COPDCOPD Discharge Bundle Hopkinson et al ThoraxCLARHC Developed by 2012:67:90-92 Pre Bundle % With Bundle % 18 100 14 68 55 98 59 91 41 39 10
  11. 11. Developed by CLARHC Hopkinson et al Thorax 2012:67:90-92CQINS to incentivise high value care 2011 11
  12. 12. One story from a respiratory ward 50+ year old manSchizophrenia since 20sTobacco addiction: 60 pack-yearsCannabis addiction:100 joint-yearsSevere COPDLives alone, isolated, not working13 admissions and 112 bed-days in 2 yearsFurther emergency admission: ‘Unable to breathe’ & severe(acute on chronic type II) respiratory failure …Due to exacerbation/worsening of severe COPD & smoking tobacco and cannabis ie sick smokerTreated on respiratory ward including non-invasive ventilation & quit smoking interventions … 50+ year old man What he told us mattered to himDisabled by breathlessnessScared to use lift to his xth floor flatToo breathless to go up stairs indoorsSleeping on piece of foam under stairsElectricity had been turned off 12
  13. 13. Care Planning Conference why and whoHigh risk of premature deathCurrent care model not workingUnder-treated schizophrenia preventing respiratory treatmentUntreated tobacco and cannabis addictionUnsafe home situationBed-days +++Respiratory team: physician, ward sister, nurse specialist, physiotherapist, occupational therapist, quit smoking advisorMental health team: care co-ordinator, dual diagnosis specialist, psychiatrist invited but unable to attendHousing officerPatient Londoners dying from smoking ‘1 in 5 deaths due to smoking’ 13
  14. 14. Care Planning Conference: what Person-centred integrated careIdentified care and treatment gaps and needsNamed actions and responsibilitiesNo social worker...Smoking as tobacco addiction NOT a life-style choiceAnti-psychotics safe – regular depot injection givenCommunity respiratory support at homeCommon needs assessment by mental health teamRehoused to supported ground level accommodation Integrated care: care planning conference Outcomes for 50+ year old man• Alive• Ground floor warden controlled flat• Mental health good, goes out regularly• Still smoking but much less• Supported at home by GP, warden, mental health team and community respiratory team as needed• Mostly telephone follow-up• No admissions in 2012 or since … 14
  15. 15. Person-centred integrated care in hospital Care planning in out-patients tooRespiratory Nurse Specialist Respiratory Physician Mental Health Quit Key Smoking Worker Advisor Delivering high value care for exacerbations of …LONG-TERM conditions in hospital • Workforce with the right competencies and interests – Respiratory knowledge, skills and expertise – Long-term conditions interest and expertise – Behaviour change and motivational interviewing skills • Design pathways around exacerbations of LTCs not episodes – Acute medical assessment unit model does not work for these patients! • Structure to admission – green days not red days – Safe respiratory failure care – Quit smoking support & medication as treatment for all sick smokers – COPD discharge bundle interventions – Diagnose & optimise care of all underlying long-term conditions • Levers – CQINS, measure value outcomes – Mortality & days at home in year or bed-days/year 15
  16. 16. A respiratory provider manifestoI am a long term conditions clinicianI care about valueI know how to assess and support patientsand drive improvementsI work in a teamI personally deliver high value care 16

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