Coordinating value based care for Londoners with COPD and asthma Dr Louise Restrick, Co-lead LRT Integrated Consultant Respiratory Physician Whittington Health & NHS Islington
Jan 02, 2016
Coordinating value based care for Londoners with COPD and asthma
Dr Louise Restrick, Co-lead LRT Integrated Consultant Respiratory PhysicianWhittington Health & NHS Islington
Who are the Londoners living with respiratory disease and what are their needs?
• People living with disabling BREATHLESSNESS
• Difficult home and social circumstances – often alone
• Quietly stoical and brave
• Tobacco (and cannabis) dependent
• High mortality with unpredictable disease trajectory
Respiratory failure - heart disease - cancer
• Multiple long-term conditions ie multi-morbidity
• Mixture of physical and mental illnesses
• Emergency admissions with frightening breathlessness +/- respiratory failure
‘I don’t want to die’
‘breathlessness is frightening and disabling’
‘hospitals and GPs don’t talk to each other enough’
What do patients & families tell us about their needs…
Language: Fear … and Hope
and aligning agendasPatients’ concern is breathlessness…
Frightening
Clinicians focus on respiratory failure
Frightening
Value Framework
Health Outcomes
Patient definedbundle of care
CostValue=
Health Outcomes Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
A respiratory provider manifesto I am a long term conditions clinician I care about value I know how to assess and support patients and drive improvements
I work in a team
I personally deliver high value care
Kindness
Respect
Empathy
Dignity
Interest
TRUST
Respiratory teams committed tocare delivered with KREDIT*
*Whittington Health, London Respiratory Team and …
Approach to patient care and team work ...
eg Schwartz Rounds
Londoners dying from smoking
‘1 in 5 deaths due to smoking’
Respiratory Disease
Cancer
Cardiovascular disease
Mental illness
Tools for coordinating value care:CCG dashboards - Tower Hamlets
Network 1 Network 2 Network 3 Network 4 Network 5 Network 6 Network 7 Network 8 Borough Total
April 39.08% 41.02% 32.35% 34.00% 38.87% 42.86% 38.63% 43.06% 38.76%
May 41.13% 40.68% 32.84% 34.41% 39.09% 43.09% 38.72% 43.36% 39.11%
June 41.11% 40.96% 31.73% 33.41% 37.94% 42.91% 39.11% 43.49% 38.84%
July 41.18% 41.71% 33.65% 33.41% 38.96% 40.82% 38.87% 43.20% 38.98%
August 40.20% 41.92% 33.96% 33.33% 38.31% 41.87% 39.12% 43.33% 39.00%
September 38.87% 42.03% 33.18% 34.73% 41.71% 43.15% 38.88% 43.85% 39.64%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
%ag
e o
f p
atie
nts
Confirmed COPD registered patients that are current smokers
40% smoking prevalence in people living with COPD
Tools for co-ordinating value care:
Systems & Quality Improvement
Academic Health Science Centres & Networks
Local Enhanced Services:
COPD & Quit Smoking
NHS Innovation Challenge
Awards 2012
Practice NursesGPs
Earlier Diagnosis
Tools for coordinating value care:BTS National Asthma Audit‘Smoking status incorporated into the 2011 audit…
32.5% patients admitted to hospital were current smokers; 18.8% ex-smokers..’
60% asthmatics admitted to one inner London hospital current smokers
Changing how we think about smoking
Tobacco dependence
Sick 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
Our clinical work - not just quit smoking advisors…
‘Smoking kills, stopping works’ Sir Richard Peto 2012
• Worsening/exacerbation of long-term condition
• Multi-morbidity
• Mix of physical and mental illnesses
• High readmission rates
…for other reasons
• High but unpredictable mortality
• Tobacco (and cannabis) dependent
Why do Londoners with emergency respiratory admissions need co-ordinated value care?
*Krumholtz NEJM 2013;268:100-102
Respiratory Pharmacist
64-71% re-admissions different reason*
Developed by CLARHCHopkinson et al Thorax 2012:67:90-92
Tools for co-ordinating value care:
COPD Discharge Bundle
*Jiminez Ruiz et al Nicotine and Tobacco Research 2011
~500 smokers with severe COPD*10 intensive interventions with
medication
44% quit at 6/12 with NRT60% quit at 6/12 with varenicline
Co-ordinating value care: Quit smoking advisors working with sick smokers as
in-patients
Pharmacist BTS
ChampionCQIN Clinical
Lead
Developed by CLARHCHopkinson et al Thorax 2012:67:90-92
COPD Discharge Bundle
Pre Bundle % With Bundle %
18 100
14 68
55 98
59 91
41 39
Co-ordination not easy!
‘Breathe Better, Feel Good, Do More’’
Co-ordinating value care: Respiratory Physiotherapists
PulmonaryRehabilitation
Co-ordinating value care: psychologists in & working with respiratory teams
Respiratory Team
Psychologist
Co-ordinating value care:
Respiratory Nurse Specialists
Community Respiratory Nurse Specialist
In-patient Respiratory Nurse Specialist
‘Hospitals and GPs don’t talk to each other enough’
Why aren’t we speaking to GPs on admission?
More than 1 in 6 people
admitted to hospital had
not seen their GP in the
previous year
Why aren’t we connecting patients with their GP?
Why aren’t we speaking to GPs at discharge?
Tools for co-ordinating value care: electronic patient records
BTS AWARD for INTEGRATION of Respiratory Services 2013
Implementing a COPD disease management system in inner NW London to improve communication and care
Enhanced Recovery
Care planning conferences …Shared decision making: agreed shared agenda
Identify & address treatment and care gaps & needs
SocialWorker
Mental Health Key Worker
Quit Smoking Advisor
Consultant Psychiatrist
… with patients & family
Occupational Therapist
Hospital & MH Social
Worker
My team or I can lay hands on …
A pulsoximeter . A contact for someone who can use a spirometer . A COPD/asthma action plan . A range of quit smoking products . A spacer . Stories and testimonies about PR . Registers of people with asthma, COPD, their smoking status and those at the end of life . An ICS safety card . A discharge bundle . LRT and Impress products . Phone numbers or an online resource for: stop smoking service, PR team, IAPT or CMHT, social care, carer support, blue badge co-ordinator, palliative care . Commissioning tools that enable improvements e.g. CQUINS/LES/LIS/NIS/DES . Tools that empower patients
‘Care is only integrated when people want it to be, otherwise it does not
happen …’ *
*LRT feedback from Londoners living with COPD 2013