Welcome! Innovation in Changing Respiratory - PowerPoint Presentation

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Welcome!Innovation in Changing Respiratory PracticeRespiratory Strategic Clinical NetworkTuesday 24 November 2015  #eoerscn Slide2

Agenda ProgrammeSpeaker09:30 – 10:15‘Take a Breath and Prepare for Winter’Working smarter together to turn winter chaos back into winter pressure

Amanda Cousins

AD of Service Improvement and Transformational Change

NELCSU

10:15 – 11:00Co-Commissioning: Is joint working between Secondary & Community Care a theory or reality?Catherine Tooley (James Paget Hospital)Carl Dodd (Great Yarmouth CCG)11:00 – 11:20Refreshments11:20 – 12:20Respiratory Pathway Re-design: The Challenges of Change – a local perspective  Examples from:Luton CCGIpswich & East Suffolk CCGAmanda FlowerAD Planned Care and Long Term ConditionsLuton CCG Dr Jonathan DouseConsultant Respiratory Physician Ipswich Hospital12:20 – 12:45Respiratory SCN Update & FutureLianne JongepierEoE RSCN Team12:45 – 13:30Buffet LunchSlide3

Amanda CousinsAD of Service Improvement and Transformational Change NELCSUSlide4

Take a breath and prepare for Winter !Amanda Cousins NEL Healthcare ConsultingSlide5

The challenge we all face1/3rd Fewer beds37 % increase in people turning up in emergency care2/3rds of urgent care patients are > 65 yearsWe need to change to survive5Slide6

How do we plan the provision of urgent or unplanned care ?Regional System Resilience Groups (share good practice and work on regional issues)Local System Resilience Groups (drive the local system development)Capacity planning Groups (operational weekly)Operational System managementUnderpinning escalation plans for trusts and for systemsCommissioner and provider on call 6Slide7

The dimensions which impact on demand – non one easy fix7Age profile of the local populationEnvironmentThe viral load or disease profile

D

emographicsSlide8

What is everyone up to ?People are all working to a common set of goals but we have different starting points, challenges and opportunities.Everyone is talking about the need for radical change and integrationThe most effective and impressive changes have been achieved by Getting back to basics and keeping things simpleInvolving the shop floor in planning improvements Overcoming tribalism and barriers to change8Slide9

Work together on the total pathway9Primary PreventionEarly DiagnosisEffective and Timely Treatment

Crisis management and recovery plans

Patients empowered to manage their own condition

NICE GuidanceSlide10

Influencing Factors: National Standards, Strategies and Guidance“Transforming Urgent and Emergency care in England – guidance for commissioners”Ongoing provision of 111 services across the country; dissemination of best practice from areas where this appears to be working well and learning from those areas where services are still struggling

Ongoing push with regard to use of smart technologies to support patient self management for long term conditions, heart failure and COPD

Ongoing push to provide services to support self management of chronic or recurring problems e.g. direct access physiotherapy for back pain patients; personal health budgets

Promotion of integrated health and social care provision for frail older people with complex needs including crisis planning and rapid access intensive support

Primary care development Mental Health Services waiting times and increased access to services (political aspirations currently)Workforce planning – guidance is around on many aspects, push for wider use of prescribers in the system ( nurses, pharmacists and physiotherapists) Some good local pilots where new initiatives are being tried so we need to learn from others.National‘‘Improving access to urgent and emergency care services seven days a week is a key national priority’’‘‘Sir Bruce Keogh’s review of urgent and emergency care services in England is the latest driver for change nationally’’‘’Urgent and emergency care networks should play a role in coordinating resources across the system’’Slide11

So what are others up to ? Visualising the future together11Slide12

Looking at the influencing Factors: Primary Care Increase in responsibility Development of new relationships with neighbouring practices to deliver high quality care (networked models of care)Promotion of equal relationships with every patient (models of shared decision making)D

rive towards 7-day services

(8am-8pm, 7days)

Population changes

Expected growth in the number of people aged 85 and older and those living with one or more long term conditions likely to rise from 1.9 million in 2008 to 2.9 million in 2018. WorkforceGradual increases in the number of GPs working part time hours.GP workforce that has only increased at half the rate of other specialities in the medical field.Over reliance on locum GPs FinanceA decrease in real time spending on GP servicesNHS England sole commissioners of Primary Care servicesIMPORTANT NOTE: The GP taskforce report identified major gaps in workforce information needed to underpin effective workforce planning. They reconfirm the recommendation of the Centre for Workforce Intelligence (CfWI) that the GP workload survey must be urgently re-commissioned, along with a more effective vacancy survey.The survey collected data from voluntary submissions up to 2010. National PositionSlide13

Setting priorities for action: Hospital Non elective admissionsAnalysis of admissions by primary diagnostic groups show that, where marked increase in admissions occur an increase in age is also apparent. This is consistent with the previous slides. [N.B. age is in the data but is not visible in the charts]

Diagnostic variations

Ave.

age on

admission increased by 4 years. Variation respect to 11/12 +16%Ave. age on admission increased by 4 years. Variation respect to 11/12 +32%Ave. age on admission increased by 4 years. Variation respect to 11/12 +140%Slide14

Looking at the detail: deep dives : Non elective admissionsRespiratory: an increasing problem

The table shows the increase in

non elective

admissions

to one acute trust associated with respiratory problems during 13/14 if compared with 11/12 (2 years). A crude calculation to convert admissions to bed days/just bed has been done to show the magnitude of the problem. The age profile of patients presenting with respiratory problems has increased significantly for respiratory infections and pneumonia.Slide15

Looking at the detailed pathway - Review of a pneumonia pathway. Dr Paul Jarvis - Consultant in Emergency Medicine. Slide16

What can you do to help your systems ?We need you to have lots of coffee and conversations with GP’s, A&E and MFE colleagues….. How can we better manage the older person with pneumonia ?How do we standardise the treatment of respiratory patients turning up in A&E including timing and who should be triaging these patients ?How can we reduce variation in the management of respiratory LTCs across practices ?16Slide17

Other developments to join up to the pathways we design Patient registers Risk stratificationMDT care deliveryRapid response teams in the communityAdvanced crisis planningPersonal health budgetsSocial and voluntary sector supportSingle points of access for specialist advice (specialist nurses)17Slide18

Pitfalls to avoidPilotitis “The NHS has more pilots than the RAF” be prepared to take a few calculated risks if something does not work then stop and think again.Talk to your local urgent care leads and you are most welcome to join we need you on board !Do not ignore the patient views - test the patient experience.18Slide19

George – use case studies to learn fromGeorge has advanced respiratory disease and is living alone at home with continuous oxygen. George used to be in the forces and he likes to be in control so he has a care plan which he has helped devise, he has the ability to self medicate if he feels unwell and he manages his own oxygen and his own personal budget from social services enables him to arrange his own home support. He likes his hobbies and uses skype to keep in touch with family abroad. What does George value….He has a much loved respiratory specialist nurse who had trained him to manage his condition and she with her team can always be accessed on the phone during working hours she visits to review regularly. Out of hours he has a local arrangement with the OOHs district nurses who he also trusts as they are briefed on his crisis plans.George has a hospital outpatient appointment which he is cancelling as he feels OK and when he does not he cannot travel anyway. He does not like crowds ! Hospitals are viewed as a hazard to his wellbeing !George wants outpatient clinics which he can skype into for advice ?George wants do more of his own testing ? 19Slide20

To know moreIf you would like to discuss any elementof this presentation, please contact Amanda CousinsTel: 01603 257025Email: Amanda.cousins@nelcsu.nhs.ukwww.nelcsu.nhs.ukSlide21

All presentations will be available on…www.respiratoryfutures.org.uk(click on ‘regions’ then ‘EoE’

Don’t forget to complete your

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(in your pack)

Are you on ?Then please tweet about today!#eoerscnYou can find all of our work on:www.respiratoryfutures.org.ukWifi code: Slide22

Integrated careCatherine Tooley & Carl DoddRespiratory Integrated Team (RIT)Slide23

The VisionTo deliver improved services for adult patients, ensuring an integrated approach to both acute and chronic respiratory disease management for patents registered with the Great Yarmouth and Waveney General Practices. Slide24

GY&W population circa 230,000Slide25

The DriversNational drivers CCGAccess to care, Equity of provisionIntegration of servicesImproved self managementQIPP Acute LOS, reduced admissions and attendancesReduced prescribing costsIncreased referrals for pulmonary rehabilitation HOSAR, smoking cessationSlide26

BackgroundCQUINNetwork development – membershipSenior nurse – backfill to lead projectSpecialist nursing support for practicesCOPD Bundle within Primary careRespiratory physician presents case to GP clinical leadsRetained GP - Clinical service reviewsshadowing community teamRespiratory wardOutlying wards Slide27

Breathe Easy /Focus Group

Involvement

Work with the walk in centres/ambulance services/palliative care to ascertain the needs of people with lung disease

Audit of JPUH Practice

Patient journeyAsthma care

Patient pathway in JPUH

Develop connections with the OOH team/community matrons and district nurses

Work with the CCG in

re-defining

what is required to reduce Attendances and admissions

Re-design the role of the RNS within the JPUH

Work with ECCH in re-designing the current Community RNS service. Combined recruitment.

Design of an Early Supported Discharge (ESD) Service

Designated respiratory consultant and senior RNS working in primary care

Data collection and analysis

Integrated Respiratory Care

What have we had to do?

Teaching programme to for the hospital and the community to upskill other HCP in Respiratory care

Working with CCG on Joint drug formulary to reflect

safe,cost

effective prescribing

Develop PDGs for the communitySlide28

The challenges beginningTwo Trusts acute & community (social enterprise) bidding for one service Uncertainty, endless meetings2 trusts actually TRUSTING each otherChange in key stakeholder personnelClarity of what the service will look like by all parties Slide29

CommunicationSlide30

Current ChallengesBusiness case approved but as yet awaiting final agreementBehind predicted timelineAwaiting honorary contractsChange in staff working patterns, JD’s, hours of service …all need to be discussed and agreed. Involves HR, different management approachBeing paid from one employer yet managed by another…. How does this feel to the employeeData collection and analysis IT ongoing, lack of systems communicating with primary, secondary care and community setting Service specification & CQRA Slide31

Helping our patients achieve their DreamsSlide32

Any Questions?Slide33

All presentations will be available on…www.respiratoryfutures.org.uk(click on ‘regions’ then ‘EoE’

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Are you on ?Then please tweet about today!#eoerscnYou can find all of our work on:www.respiratoryfutures.org.ukWifi code: Slide34

Respiratory Pathways ProjectAmanda Flower, AD Planned Care, Luton CCGSlide35

‘Creating Confidence, Pride, and a Positive Image for Luton’Slide36
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Facts about Luton£230m budget for Health Services (deficit)Population 220,000 registered with 30 GP PracticesSlide38
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Variation:Recorded prevalence on practice disease registers:COPD Regional 1.8%Luton 1.2%, range 0.3% - 2.2%Asthma Regional 6.1%Luton 5.4%, range 3.3% - 8.4%Non elective admissions: COPD - range from 1.35 admissions per 1,000 weighted list size to 6.60 admissions per 1,000 weighted list sizeAsthma – range from 0.58 per 1,000 weighted list size to 5.89 admissions per 1,000 weighted list size Slide41
Slide42

Why?Slide43

JSNA RecommendationsSlide44

Providers:30 GP PracticesCambridgeshire Community Services NHS TrustLuton & Dunstable Hospital NHS Foundation TrustLive Well LutonEast London NHS Foundation TrustSlide45

The System Challenge:1. Significant variation2. Duplication3. Joint working Slide46

Primary Care:Multi Disciplinary Practice Visits Practice dashboardShare good practice Raise awareness of guidelines Local respiratory resource folder ‘Enhanced’ primary care disease template Use of OPC Audit Tool to target patients in need of review and intervention to optimise their care Practice questionnaire – training – how care is organised/deliveredTraining (needs identified through questionnaire)Community respiratory nurses aligned to practices Slide47

MDT Practice Visits2 plus 8 (probably all eventually)GP Clinical Lead, ChairPractice TeamRespiratory Nurses – Acute and CommunityConsultant in Respiratory MedicineMedicines Management and OptimisationClinical Specialist Physio2 HoursGuidelines and PathwaysDashboard3 case discussionsBrief action plan to be followed up by community serviceSlide48

Optimum Patient Care:Tailored practice reports compare outcome measures with that of the general service. The reports allow the practice to target patients in need of review and intervention to optimise care and help the practice to achieve QOF targets. The practice report covers:Diagnosis – potentially undiagnosed patientsPatient demographicsDisease control and severityRisk stratification and exacerbationsAdherence and concordance with therapyPatient reviews and self-management plansManagement and therapy recommendations based on guidelinesFocus areas for improvementSlide49

Optimum Patient Care:The individual level patient reports will support clinicians to identify high risk patients and other patients who would benefit from review and intervention to optimise care. The reports include:Identification of high risk patientsPatients associated with recommendations in practice reportsDisease symptoms and controlCo-morbidities and smoking statusTherapy status and overview Slide50

Optimum Patient CareSlide51

Any Questions?

Amanda Flower

Assistant Director of Planned Care

Amanda.flower@lutonccg.nhs.uk

Thank-you for listening. Slide52

All presentations will be available on…www.respiratoryfutures.org.uk(click on ‘regions’ then ‘EoE’

Don’t forget to complete your

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Developing the Respiratory PathwayJonathan Douse Ipswich HospitalSlide54

O

2

ESD

PR

The Current System

IHT

(Physio, LFU, Chest Clinic, ED)

42 Primary Care Practices

Liaison

Psychiatry

Suffolk Wellbeing Service

Social Care

COPD Service

District Nurses

Community Matrons

Suffolk Family Health

Live Well Suffolk

Palliative Care

Dietetics

Patient GroupsSlide55

Why change?Multiple providers of servicesLack of joined up working (inefficient)Perverse incentivesDisjointed experience for patientsMore outpatient demand than capacityNot all necessaryEscalation beds in usePatients recurrently admittedLength of stay longer than necessarySlide56

The futureIntegrated Respiratory ServiceImprove quality of care for patientsReduce unnecessary admissionsReduce unnecessary outpatient attendancesResponsible prescribingSave money for greater healthcare economyImproved patient experienceSlide57

Getting thereJoint prescribing guidelinesCQUIN 2014-15Liaison psychiatryEnd of life careRespiratory networkClinical Leaders TrainingReview of other “integrated” servicesNational policySlide58

O

2

ESD

PR

The Pilot Jan –June 2015

Specialist nurse working with 15 pilot practices (joint clinics, prescribing support, complex case review)

Specialist nurse working in IHT, case finding and discharge support

Consultant facilitating weekly MDT and input to primary care

New psychological support via Suffolk Wellbeing Service via OP clinic and Pulmonary rehab

COPD service involved in weekly MDT

Supporting winter scheme use of GRASP

IHT

(Physio, LFU, Chest Clinic, ED, Psychiatric Liaison)

15 Pilot Primary Care Practices

Liaison

Psychiatry

Suffolk Wellbeing Service

Social Care

COPD Service

District Nurses

Community Matrons

Suffolk Family Health

Live Well Suffolk

Palliative Care

Dietetics

Patient Groups

(A)

New Nurse Specialist

(B)

New Nurse Specialist

New

Weekly

MDT

ConsultantSlide59

Outcome of the PilotProject cost £91,000There were reduced pharmacy costs The whole year effect was worth £124,000Hospital Length of stay (February-June) was reduced for patients with asthma and COPD by 0.91 days compared to the same period in 2014 and 0.38 days compared to the period July-November. Slide60

Outcome of the PilotReadmission rate was reduced by 3%51 new outpatient appointments were avoided saving £9,592.There was an increase admissions for COPD and asthma from both pilot and no-pilot practicesSlide61

Feedback from PilotPatient feedback was excellentPrimary care staff who greatly valued the training they had receivedSlide62

Getting furtherClinical transformation GroupService specification for integrated respiratory serviceReleased Nov 2015Setting up the model of future careFunding and KPIGetting started Summer 2016Slide63

What have I learnt?Investigate the agendas of all partiesTakes timeAlign incentivesGet a sponsor on the CCGVia clinical networkMake most of existing servicesGet the patients involvedSell the visionSlide64

Any questions?Slide65

All presentations will be available on…www.respiratoryfutures.org.uk(click on ‘regions’ then ‘EoE’)

Don’t forget to complete your

evaluation form

(in your pack)

Are you on ?Then please tweet about today!#eoerscnYou can find all of our work on:www.respiratoryfutures.org.ukWifi code: Slide66

Lianne JongepierEast of England Respiratory SCN ManagerStrategic Clinical NetworksNHS EnglandSlide67

Thank you.Hope to see you again Respiratory Strategic Clinical NetworkTuesday 24 November 2015  #eoerscn