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Integrated Respiratory Care: what, where, how?

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Integrated Respiratory Care: what, where, how?

  1. 1. Integrated respiratory care: what, why, how? Dr Irem Patel, Integrated Consultant Respiratory Physician King’s Health Partners 16th June 2016 Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily represent the views and policy of PLAN(Pan London Airways Network).
  2. 2. • Definition of integrated care • Drivers: historical • Drivers: present • Current emphasis • Informing principles • Models and evidence in COPD • Roles and skills of an integrated respiratory clinician/team Learning outcomes: to understand.. Page 2
  3. 3. What is integrated care? Page 3 DoH: NHS Next Stage Review 2008 “healthcare professionals working on a collaborative basis with clear leadership, shared goals, and shared information, designing services around the needs of individuals and local communities’ King’s Fund: 2012 “an approach that seeks to improve the quality of care for individual patients, service users and carers (as people) by ensuring that services are well coordinated around their needs……must impose the user’s perspective as the organising principle” BTS: Position Statement on Integrated Care 2014 “the best possible care for the patient, delivered by the most suitable health professional, at the optimal time, in the most suitable setting”
  4. 4. Vertical integration across all healthcare sectors Page 4 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist
  5. 5. Vertical integration across all health and social care Page 5 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist
  6. 6. Horizontal integration across common comorbidities Page 6
  7. 7. Drivers for integration: historical Page 7 1948 With thanks to Professor Martyn Partridge
  8. 8. Original structure of healthcare Page 8 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist
  9. 9. Original structure of healthcare Page 9 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist
  10. 10. Original structure of healthcare Page 10 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist HOSPITAL BASED COMMUNITY BASED
  11. 11. Original structure of healthcare (UK, Canada, Scandinavia, Netherlands, Australia, New Zealand etc) Page 11 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist HOSPITAL BASED COMMUNITY BASED
  12. 12. Original structure of healthcare (variations in US and some European countries) Page 12 Patient Generalist Specialist Hospital care HOSPITAL BASED COMMUNITY BASED
  13. 13. Significant changes in healthcare needs and delivery have taken place in last few decades, mostly in: • unplanned way with • unintended consequences Page 13
  14. 14. Significant changes in healthcare needs and delivery have taken place in last few decades, mostly in: • unplanned way with • unintended consequences Page 14
  15. 15. Unplanned changes to this model 1990-2015 Page 15 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist SUPER SPECIALISATION: Opting out of General Medicine
  16. 16. Unplanned changes to this model 1990-2015 Page 16 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist Development of Acute Medicine and AMU
  17. 17. Unplanned changes to this model 1990-2015 Page 17 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist Acute Physician
  18. 18. Unplanned changes to this model 1990-2015 Page 18 Exponential rise in primary care consultations 2000-2008: Increasing pressure on primary care Source; NHS Information Centre
  19. 19. Unplanned changes to this model 1990-2015 Page 19 Exponential rise in primary care consultations 2000-2008: Increasing pressure on primary care Source; NHS Information Centre Off loading by hospitals Increasing population Increasing longevity Increasing expectations Changing health burden
  20. 20. Changing health burden: Causes of morbidity/mortality NHS was set up for Page 20 With thanks to Professor Martyn Partridge
  21. 21. Causes of morbidity/mortality NHS deals with now: Page 21 60% of global deaths are due to chronic disease 70% 30% Total NHS spend England LTC Other LTCs account for: 75% inpatients 65% outpatients 65% primary care OPAs Murray. Lopez et al Lancet 2005 DoH Long Term Conditions estimates 2010
  22. 22. Changes to health care professional roles: nursing/AHP Page 22
  23. 23. Changes to health care professional roles: nursing/AHP Page 23 April 1981 The respiratory health worker With thanks to Professor Martyn Partridge
  24. 24. More recently, emergency care further compromised Page 24 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist No longer responsible for emergency care
  25. 25. Succession of possible solutions Page 25 Patient Primary care Generalist Secondary Care Specialist Tertiary Care Super Specialist No longer responsible for emergency care Out of hours services Deputising Services Cooperatives Walk in clinics Urgent care centres
  26. 26. Unplanned solutions: a vast array of options Page 26 Patient Doctor Specialist Super specialist Gerontologist Specialist nurse/physio Acute Physician Nurse Physician Associate Nursing Assistant Pharmacist Lay educator
  27. 27. Significant changes in healthcare needs and delivery have taken place in last few decades, mostly in: • unplanned way with • unintended consequences Page 27
  28. 28. “Medicine’s complexity has exceeded our individual capabilities as doctors… …we’re all specialists now—even primary- care doctors… …the public’s experience is that we have amazing clinicians and technologies…but little consistent sense that they come together to provide an actual system of care, from start to finish, for people….” http://www.newyorker.com/online/blogs/newsdesk/2 011/05/atul-gawande-harvard-medical-school- commencement-address.html#ixzz25QFENvfV
  29. 29. Fragmented care Poor patient experience – elderly polymorbid people having multiple consultations with heart failure CNS/bone clinic/chest physician/diabetes CNS/pulmonary rehab physio…… Unwarranted variation in: • access to care • organisation of care • outcomes Unsustainable system (demoralised workforce) Unintended consequences: Page 29
  30. 30. Workable ideas have come mostly from HCPs rather than NHS managers Current emphasis on integration Page 30 2014 6 case studies across UK •Rheumatology •Child health •Gerontology •DM •Dermatology/minor surgery •Respiratory Integrated consultant roles that span hospital and community settings and include strategic responsibilities for service planning across sectors. These provide the capacity and drive for consultants to work outside the hospital on top of their usual duties.
  31. 31. RCP Future Hospital Program Page 31 Sept 2013 Our vision of the future hospital: a new model of clinical care Hospitals will be responsible for delivering specialist medical services (including internal medicine) for patients across the health economy, not only for patients that present to the hospital. Much specialist care will be delivered in or close to the patient’s home. Physicians and specialist medical teams will expect to spend part of their time working in the community, providing care integrated with primary, community and social care services.
  32. 32. Page 32 Oct 2014 “Multispecialty community providers” As larger group practices they could in future begin employing consultants or take them on as partners, bringing in senior nurses, consultant physicians, geriatricians, paediatricians, and psychiatrists to work alongside community nurses, therapists, pharmacists, psychologists, social workers and other staff… These practices would shift the majority of outpatient consultations and ambulatory care out of hospital settings..
  33. 33. Page 33
  34. 34. So what is the problem in respiratory medicine? Page 34 2014 Resp diseases affect 1 in 5 people in UK 1 million hospital admissions - £5 billion 3rd biggest cause of death in UK 80,000 deaths/year plus 35,000 to lung ca Worst mortality cf OECD
  35. 35. So what is the problem in respiratory medicine? Page 35 2014 Resp diseases affect 1 in 5 people in UK 1 million hospital admissions - £5 billion 3rd biggest cause of death in UK 80,000/year plus 35,000 to lung ca Worst mortality cf OECD
  36. 36. Page 36So what is the problem in respiratory medicine?
  37. 37. Page 37So what is the problem in respiratory medicine? 46% of deaths could have been prevented 65% one or more avoidable factors
  38. 38. NRAD: Primary Care Factors 138 GP practices 83% full QOF points for asthma Time from asthma review to death median 121 (IQR 30-306) days Where primary care was last asthma review before death: n=135 • 27% had assessment of control • 42% medication use review • 71% had assessment inhaler technique • 24% had a personalised asthma action plan • 22% missed appt; in 55% practice attempted to follow-up • 57% not under secondary care in year before death 46% of deaths could have been prevented
  39. 39. NRAD: Secondary Care Factors • 30% in hospital arrest • 47% had history of previous hospital admission • 10% died within 28 days of discharge • 21% had attended ED >1 in previous year • 68% no follow up after hospital • 19% had not been referred to specialist care 46% of deaths could have been prevented
  40. 40. NRAD: Secondary Care Factors • 30% in hospital arrest • 47% had history of previous hospital admission • 10% died within 28 days of discharge • 21% had attended ED >1 in previous year • 68% no follow up after hospital • 19% had not been referred to specialist care 1 in 5 (23%) were current smokers 36% childhood deaths in smoking families
  41. 41. 165 patients where SABA prescription info available: • 39% had >12/year prescribed • 6 (4%) had >50/year 128 patients where ICS prescription info available: • 49 (38%) had <4/year • 103 (80%) <12/year 5 patients who died were on LABA monotherapy: • 2 not prescribed corticosteroid and 3 not collecting 39% severe asthma; 49% moderate asthma; 14 ‘mild’ asthma NRAD: Prescribing factors
  42. 42. So what is the problem in respiratory medicine? COPD: • A story with no beginning…… • A middle that is a way of life…… • An unpredictable and unanticipated end…… Hilary Pinnock et al, BMJ 2011; 342 Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group
  43. 43. Harm and waste due to high dose ICS 98 practices in SE London 41 practices agreed to share data 310,775 patients 3537 patients with COPD diagnosis (1.14%) IMD score in most deprived quintile of UK COPD: misdiagnosis, inappropriate Rx and harm
  44. 44. 35% of patients on COPD register did not meet criteria by spirometry
  45. 45. COPD: misdiagnosis, inappropriate Rx and harm Spirometry and exacerbation frequency in previous 12 months 38% over treated with inhaled steroids (ICS) 469 patients without spirometry confirmed COPD or asthma = 51% on ICS •12 additional cases of pneumonia per year? •Cost: £500,000 per year (2 boroughs)
  46. 46. Page 46 Price et al. Prim Care Respir J 2013; 22(1): 92-100
  47. 47. Hospital care: Ready for home? British Lung Foundation Patient survey 2010 75% did not feel ready to leave hospital on d/c 37% felt reassured that there would be support at home 34% felt informed about COPD and the reasons for their admission 31% felt confident their medications were helping 34% confident about spotting early signs of a flare up next time 25% felt positive about the future 26% delayed getting help/treatment before admission
  48. 48. Hospital care: Ready for home? BLF Patient Survey 2010 Post exacerbation 29% had increased their levels of activity/exercise 35% had renewed efforts to stop smoking 27% had been involved in discussion forum 27% had been contacted by community services 59% had primary care f/u arranged 61% had secondary care f/u arranged
  49. 49. Hospital care: Ready for home? BLF patient survey 2010 Patients would like 75% – more information about reason for admission 75% – contact from community professionals 69% – practical advice re lifestyle etc 64% – telephone advice/support
  50. 50. Cost of treatment for an acute exacerbation of COPD O'Reilly et al. Int J Clin Pract 2007;61:1112–20 £110 £1,536 £484 £0 £200 £400 £600 £800 £1,000 £1,200 £1,400 £1,600 £1,800 Medication Hospitalization Other services and investigations Treatmentcostforanacuteexacerbation UK health economy £810–930 million/yr
  51. 51. Cost of treatment for an acute exacerbation of COPD O'Reilly et al. Int J Clin Pract 2007;61:1112–20 £110 £1,536 £484 £0 £200 £400 £600 £800 £1,000 £1,200 £1,400 £1,600 £1,800 Medication Hospitalization Other services and investigations Treatmentcostforanacuteexacerbation UK health economy £810–930 million/yr
  52. 52. So what is the problem in respiratory medicine? Page 52 National COPD audit 2014 57% seen by resp consultant during admission 42% managed on resp ward 37% current smokers (32% in 2008 and 40% in 2003) 58% had evidence of smoking cessation Rx (64% if seen by resp versus 32%) 90% known to have COPD before adm but 46% had spirometry recorded in last 5 years 44% had no assessment of suitability for PR 30% no discharge bundle 38% access to PR within 4 weeks of d/c
  53. 53. Informing principle 1= value Informing principle 2 = right care Do the right things Do things right www.rightcare.nhs.uk So…….what are the solutions? Page 53 Porter ME, Lee TH. NEJM 2010; 363: 2477-2481 2481-2483 COPD Value Pyramid: LRT 2010
  54. 54. What is high value in COPD?
  55. 55. Londoners dying from smoking ‘1 in 5 deaths due to smoking’ What is the most important outcome for patients?
  56. 56. 0 10 20 30 40 50 60 70 80 90 100 ENGLAND LONDON SouthwarkPCT CityAndHackney… LewishamPCT IslingtonPCT TowerHamletsPCT NewhamPCT LambethPCT HammersmithAnd… Greenwich… CamdenPCT WandsworthPCT HounslowPCT KensingtonAnd… BrentTeachingPCT EnfieldPCT WestminsterPCT EalingPCT CroydonPCT SuttonAndMerton… WalthamForestPCT BromleyPCT BexleyCareTrust HillingdonPCT HaringeyTeaching… RedbridgePCT HarrowPCT HaveringPCT BarnetPCT RichmondAnd… KingstonPCT %COPDregisteredpatientswhosmoke(iftheirsmoking statusisrecorded) London PCTs QOF Smoking prevalence in COPD At best one in four Londoners with COPD are still smokers….
  57. 57. Quit smoking as high value TREATMENT for COPD and therefore a core skill for the COPD specialist Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65:711-718 1 year abstinence % QALY £ Usual care 1.4 Minimal counselling 2.6 14,735 Intensive counselling 6 7,149 Intensive counselling + pharmacotherapy 12.3 2,092 Tiotropium £7,112/QUALY Eur J Health Econ. 2007; 8(2): 123135
  58. 58. Page 58
  59. 59. Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group High value long term care in COPD PULMONARY REHAB NNT = 4 to prevent one COPD readmission
  60. 60. The right inhaler, first time
  61. 61. London Respiratory Team High value (“right care”) approaches: COPD value pyramid
  62. 62. Page 63 “Clinicians need to accept that they are responsible for the stewardship of resources and not just their use”. Sir Muir Gray BMJ 2012
  63. 63. Hospital at Home for COPD Admission avoidance/Early supported discharge  Multidisciplinary assessment  Nursing support at home  Remain under specialist team  Cochrane Review 2012: Reduced readmission rates and trend to reduced mortality (Jeppesen et al CD003573 DOI: 10.1002/14651858.CD003573.pub2) Thorax 2007; 62: 200-210
  64. 64. Hospital at Home for COPD Admission avoidance/Early supported discharge  Multidisciplinary assessment  Nursing support at home  Remain under specialist team  Cochrane Review 2012: Reduced readmission rates and trend to reduced mortality (Jeppesen et al CD003573 DOI: 10.1002/14651858.CD003573.pub2) Thorax 2007; 62: 200-210
  65. 65. Models and evidence for integrated respiratory care in COPDPage 66
  66. 66. COPD: organisation of care improves outcomes Guideline based therapy Regular review – clinical registry Individualised self management Advanced access to knowledgeable HCP Decision support Clinical information systems Improved outcomes Adams et al. Arch Int Med 2007;167:551–6 Steuten et al Int J COPD 2009;4:87–100 Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group
  67. 67. Integrated care for COPD Usual care Integrated care Self management education Individual care plan Shared with primary care Access to nurse care manager 12 months 50% reduction in re-admission rates Improved COPD knowledge, identification and treatment of exacs and Rx adherence Casas et al. Eur Respir J 2006;28:123–39 155 patients FEV1 45% predicted Discharged from hospital
  68. 68. Intermediate care for COPD Usual care Intermediate care Pulmonary rehabilitation Individual care plan Monthly phone calls 3 monthly home visits 24 months Reduced Primary Care Consultations Increased self management of exacerbations REDUCTION IN DEATHS DUE TO COPD 122 patients FEV1 43–49% predicted Discharged from hospital Sridhar et al. Thorax 2008;63:194–200
  69. 69. Technology assisted integration: enhanced access Home rescue therapy 24 hr access to telephone advice Respiratory specialists; web based database 258 calls over 20,000 f/u days 45% reduction in admissions 37% reduction in bed days High patient satisfaction Hurst et al. Prim Care Resp J 2010;19:260–5 74 COPD patients FEV1 44% predicted 30% long term oxygen therapy 46% lived alone ‘High risk’
  70. 70. Integrated disease management program for COPD Usual care CDM Program Disease specific education Action Plan Monthly follow up calls 12 months COST BENEFIT: SAVING $593/patient 743 patients VA USA Severe COPD Hx in prev 12 months of Hospital admission or LTOT or Oral prednisolone Rice et al. AJRCCM 2010; 182(7); 890-6
  71. 71. Page 72 “……..it is becoming clear that reliance on individual management approaches is insufficient to deal with the complex problems of COPD. In fact, the way that care is delivered is likely to be more important than the precise details of what comprises that care..” PMA Calverley Prim Care Respir J 2011; 20(2): 109-110
  72. 72. “a continuum of patient centred services organised as a care delivery value chain for patients with chronic conditions…… ….optimal daily functioning and health status for the individual…
  73. 73. Cochrane Review of Integrated Care for COPD: 2014 •26 trials involving 2997 people •Mean age 68 years, 68% male, mean FEV1% predicted 44.3% •Healthcare settings: primary (n = 8), secondary (n = 12), tertiary care (n = 1), both primary and secondary care (n = 5) •Statistically and clinically significant improvement in disease-specific QoL on all domains of the Chronic Respiratory Questionnaire after 12 months •Reduced hospital admissions •LOS significantly lower compared with controls after 12 months (MD -3.78 days; 95% CI -5.90 to -1.67, P < 0.001)
  74. 74. Evolving evidence base Page 75
  75. 75. Hospital Care Bundles: Structured admissions and enhanced recovery CARE BUNDLES • Admission an opportunity for high value interventions • Specialist review • Structured admission • Make every bed day count • Enhanced recovery • Supported discharge • Follow up Southwark Clinical Commissioning Group Lambeth Clinical Commissioning Group Nicholas S Hopkinson et al. Thorax 2012;67:90-92
  76. 76. Oxygen – doing it right Page 77
  77. 77. Advance care planning, avoiding harm Page 78 Patient Specific Protocols Shared with LAS, ED and GP Kept at patient’s home Controlled oxygen Ventilatory failure Expression of wishes Advance care plans
  78. 78. Respiratory Virtual Clinics Page 79 Practice nurse Respiratory pharmacist GP Practice pharmacist Respiratory Consultant
  79. 79. Respiratory Virtual Clinics Page 80 Review high value messages Reiterate referral pathways Reinforce respiratory prescribing messages Review pre-selected caseload of patients: 20-40 Accurate diagnosis Appropriate long term management Complex patients Relationship building
  80. 80. 2014-2015: 94% of practices in Lambeth and Southwark hosted a VC Evaluation = 4/5 or 5/5 Data from 25 VCs: • 372 patients on COPD registers reviewed • 321 (86%) patients had their diagnosis of COPD confirmed • 279/321 (87%) patients had a recommendation made • Recommendations included: 64 (23%) referrals to PR 45 (16%) referrals for smoking cessation support 41 (15%) patients to initiate a LAMA 16 (6%) patients to initiate a LABA 198 (71%) patients to step down/withdraw the ICS Respiratory Virtual Clinics: snapshot data SE London Page 81 D’Ancona GM,, Patel I, Saleem A et al. Thorax 2014;69:A90 doi:10.1136/thoraxjnl-2014-206260.179
  81. 81. Outcomes: reduction in high dose inhaled steroid prescribingPage 82 VIRTUAL CLINICS
  82. 82. Outcomes: cumulative savings of £350,000 over 7 quarters
  83. 83. Outcomes: shift to higher value intervention for a populationPage 84 50% increase in PR referral from primary care
  84. 84. Outcomes: COPD admissions in Lambeth and Southwark Page 85 KCH – COPD Acute Admissions HRG Codes 2012-13 2013-14 %change 2014-15 %change COMPLEX COPD ADMISSIONS Dz21A 164 164 0.00 192 17.07 DZ21B 1 4 300.00 4 0.00 DZ21E 14 20 42.86 28 40.00 DZ21F 5 4 -20.00 4 0.00 DZ21G 1 4 300.00 0 -100.00 UNCOMPLICATED COPD ADMISSIONS DZ21H 124 116 -6.45 96 -17.24 DZ21J 132 120 -9.09 92 -23.33 DZ21K 40 28 -30.00 8 -71.43 Total admissions 481 460 -4.37 424 -7.83 DZ21K Length of stay 2012-13 2013-14 %chang e 2014-15 %change DZ21K LOS 4.45 3.41 -23.37 3.7 8.50 DZ21K Admissions 40 28 -30.00 8 -71.43 Total COPD admissions reduced by 8% 34% reduction in COPD admissions (without cc) LOS reduced by 17%
  85. 85. BTS position statement 2014 Page 86 Community TB provision Home mechanical ventilation Admission avoidance and Early Supported Discharge for COPD Home Oxygen review
  86. 86. Summary: Roles of an integrated respiratory clinician/team Page 87 In hospital: Supporting patients to ‘get better’ as quickly as possible Act on what matters to patients Right diagnoses and right treatment – multi-morbidity Supporting safe transition home Supporting patients to live better with their long term condition(s) Planning ahead including taking actions to prevent a next admission In the community Supporting accurate diagnosis and high value management (spirometry, PR, responsible respiratory prescribing, home oxygen services) Virtual clinics, MDTs Medical support for H@H and admission avoidance schemes Accessible specialist advice and ongoing skill transfer Assessing complex breathlessness Advance care planning
  87. 87. Summary: Roles of an integrated respiratory clinician/team Page 88 In hospital: Supporting patients to ‘get better’ as quickly as possible Act on what matters to patients Right diagnoses and right treatment – multi-morbidity Supporting safe transition home Supporting patients to live better with their long term condition(s) Planning ahead including taking actions to prevent a next admission In the community Supporting accurate diagnosis and high value management (spirometry, PR, responsible respiratory prescribing, home oxygen services) Virtual clinics, MDTs Medical support for H@H and admission avoidance schemes Accessible specialist advice and ongoing skill transfer Assessing complex breathlessness Advance care planning NOT JUST FOR COPD! BRONCHIECTASIS INTERSTITIAL LUNG DISEASE VENTILATORY FAILURE SLEEP DISORDERED BREATHING HARD TO REACH GROUPS: SERIOUS MENTAL ILLNESS SUBSTANCE MISUSE PRISONS…
  88. 88. Expanded existing skill set leading a team/within team multidisciplinary working teaching, training and communication service development improvement methodology evaluation and sharing learning Integrated working demands respiratory clinical expertise PLUS: a new frontier… Page 89
  89. 89. A new skill set leading a team multidisciplinary working teaching, training and communication service development improvement methodology evaluation and sharing learning Integrated working demands respiratory clinical expertise PLUS: a new frontier… Page 90 Long term conditions expertise Strong general medicine Balancing risk – out of hospital settings Understanding population health Shared decision making Collaborative care planning Motivational interviewing
  90. 90. Thank you
  91. 91. Possible roles for integrated respiratory specialist Page 92
  92. 92. Possible roles for integrated respiratory specialist Page 93
  93. 93. Possible roles for integrated respiratory specialist Page 94
  94. 94. Possible roles for integrated respiratory specialist Page 95
  95. 95. Possible roles for integrated respiratory specialist Page 96
  96. 96. Possible roles for integrated respiratory specialist Page 97 PRISONS?
  97. 97. Training: already in curriculum Page 98
  98. 98. Training: already in curriculum Page 99
  99. 99. Training: already in curriculum Page 100
  100. 100. Page 101Training: what else is needed?
  101. 101. THANK YOU Page 102

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