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

1. Pro-active management
Stephen Gaduzo
GP, Stockport
Plan
• Stratification
• Structured review
• Management of stable disease
• Consistent messages
• Integrated care
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2. Stratification
When to start treatment?
100
Severe
FEV1 (% of predicted)
Symptoms
50
Asymptomatic
Lung Lung
20 function function
normal reduced
Mild
Axis of progression
Adapted from Sutherland E N Engl J Med 2004; 350: 2689–2697.
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3. Early diagnosis & treatment
Annual cost of treatment for COPD patients
Mild £98
Moderate £1021
Severe £3944
Very severe £6475
Prevention – Listen to your lungs
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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 admission
Garcia 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 register
NHS Salford 2010
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5. 9
School Nurse Training
Employers engaged by Oct 2012 No. of school nurses
Lancashire FT and partners 113
Liverpool Community Health 90
Bridgewater 100
Stockport 30
Tameside and Glossop 22
Central and Eastern Cheshire 47
Blackpool 25
• Local Authority workforce training
• CCG asthma master class
• Asthma awareness
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6. Structured review
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7. • How many COPD patients have NO
co-morbidity?
• How many COPD patients have NO
co-morbidity?
• 18%
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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 Delirium
Allen SC et al Age and Ageing 1997
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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.
inconvenience
Holgate 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
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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
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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
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12. Outcomes Strategy
Respiratory Clinical Pathway Team
Respiratory health & good lung health
Early accurate diagnosis
Active partnership between HCPs and patients
Chronic disease management
Tailored, 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
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13. Greater Manchester Inhaler Technique
Training
http://wires.wessexhiecpartnership.org.uk/video-series/inhaler-technique/
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Variation & the power of data
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14. Stockport PCT
Stockport 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%
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15. Practice
(reviews)
Exception
reports
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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
manage
Hibbard et al Health Serv Res 2005 Hellmans M abstract PCRJ 2012
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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
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19. Educate and support patients and practice team to
reduce risk of admission
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20. NW Integrated Care Bundle
Listening to your voice
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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 Services
Working 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
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22. Walk the 7 steps to the best COPD care
I 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
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