The document describes respiratory care strategies from several NHS boards in Scotland. It discusses initiatives like anticipatory care plans, pulmonary rehabilitation programs, self-management plans for COPD and asthma, telehealth/telemonitoring pilots, and community respiratory warning systems. Several boards reported reductions in hospital admissions, length of stay, and bed occupancy from these anticipatory care strategies.

1. Maureen Carroll
Chair, National Advisory Group for Respiratory MCNs
ANTICIPATORY CARE
STRATEGIES

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 Scotland
Reporting 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. National Advisory Group for Respiratory MCNs
Remit:
 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. National Advisory Group for Respiratory MCNs
Scope:
 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 way
Membership:
 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

6. 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)
Finding
Awareness Population Wide Prevention, Health Improvement &
Raising Health Promotion

7. 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

8. 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

9. 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

10. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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)

24. NHS Dumfries & Galloway Respiratory MCN
Community Respiratory Warning System (CREWS)
 Mainstream CREWS
 Nurse Led Service
 Direct Contact with RNS
 Community Nurse Involvement
 Home Medication Packs (partial implementation)

25. NHS Dumfries & Galloway Respiratory MCN
CREWS 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

26. CREWS Equipment

27. 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

28. 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

30. 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

32. COPD Telehealthcare Project
Outcomes Data for all 4 GP Practices
160
140
GP Audit 01/04/07 - 31/03/08
No's 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)
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33. Outcome Measures:
Outcome Median p-value
Hospital Admissions 1 vs. 0 <0.001*
Home Medication 0 vs. 2 <0.001*
(Antibiotics/Steroids)
GP Visits 3 vs. 1 0.23
A&E Visits 0 vs. 0 0.14
*Statistically significant

34. Two Sides of the Same Coin:
Stakeholder Corporate Objectives
Objectives
Outreach Spirometry HEAT: H6, E4, E5, E6, E7, A10, T10
LTC: Anticipatory Care
Patient Experience
Self-management & HEAT: H6, E5, E6, E7, A10, T6, T8, T10
LTC: Self-management
Pulmonary Rehabilitation Patient Experience
Respiratory Home Support HEAT: H6, E4, E5, E6, T6, T8, T10, T12
LTC: Self-management, Anticipatory Care,
Service Care Management
Patient Experience
COPD Telehealthcare HEAT: H6, E5, E6, T6, T8, T10, T12
LTC: Self-management, Anticipatory Care,
Care Management
Patient Experience

35. 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

36. Questions