Parallel Session 1.6.1 Managed Clinical Networks and Quality Improvement: A Distinctively Scottish Approach

Maureen CarrollChair, National Advisory Group for Respiratory MCNs

ANTICIPATORY CARE STRATEGIES

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

National Advisory Group for Respiratory MCNsRemit: 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

National Advisory Group for Respiratory MCNsScope: 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

COPD Population Model

Professional CareSelf Care

Hospital at Hospital at Home Home

Pulmonary Pulmonary RehabilitationRehabilitation

SpirometrySpirometry

Level 3Level 3Complex co-morbidity Complex co-morbidity

3 – 5%3 – 5%

Level 2Level 2Poorly controlled single Poorly controlled single disease 15 – 20%disease 15 – 20%

Level 1Level 1Well controlled Well controlled (70-80% of LTC (70-80% of LTC population)population)

Population Wide Prevention, Health Improvement & Health Promotion

Self-Self-management & management & Self-care Self-care

Awareness Awareness RaisingRaising

Case Case FindingFinding

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

NHS Lothian Respiratory MCN

Self-management plansCOPDPaediatric AsthmaAdult Asthma

Asthma & COPD Electronic GP Reminders emphasising:Self-management PlansCOPD RehabilitationPost-exacerbation follow-upAnnual ReviewAsthma ACT

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 2010Admissions stableBed Days stable

NHS Fife Respiratory MCN

Scottish Enhanced Service Programme: COPD Rehabilitation & Anticipatory Care COPD Action / Self-management Plan2010/2011 47 GP Practices participated 2011/2012 52 GP Practices participated

EMIS / VISION COPD & Asthma Patient Annual Review Templatesincorporate ‘Asthma/COPD Self-management given’

field & electronic link to the plan Asthma Patient Focus Groups to inform review of

pathways

NHS Western Isles Respiratory MCN

Well North ~ COPD eClinical Referral Guidelines

COPDAsthma Spirometry Pulmonary Rehabilitation www.wihb.scot.nhs.uk/sharedguidelines/index.html

Sleep Apnoea4 Community Staff trained in assessment Local service provided to 40 patients

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

NHS Forth Valley Respiratory MCN

Case Finding within Smoking cessation Clinics, Keep Well, Well Man & Prison Service

COPD Awareness Campaigns Self-management Plans

AsthmaCOPD

COPD Hand Held RecordAntibiotics & Steroids via PGD

COPD Telehealth Pilot Alert to Asthma Campaign in partnership with Local Authorities

Education Department

NHS Greater Glasgow & Clyde Respiratory MCN

An Integrated Prevention FrameworkQuantitative Focus on Risk FactorsIntegrated Spectrum of Primary, Secondary & Tertiary

Prevention to reduce Unplanned Healthcare Prioritisation of Intervention

Respiratory Disease:Multiple Brief Intervention: Smoking CessationAsthma Guideline & Self-management PlansCOPD Guideline & Self-management Plans

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 yearsStable readmission rates

COPD Home Care Project:Exacerbation of COPD – patients supported at home by GP

& RCNS Supportive Palliative Care , including Anticipatory care Plans

NHS Greater Glasgow & Clyde Respiratory MCN

COPD Local Enhanced ServicePractice Nurse training Smoking cessation advice & referral process

Asthma Care Plans Community Pharmacy

COPD TrainingCOPD Medication Review Respiratory MCN Prescribing Group established to

oversee use of respiratory medications Patient Pathway – all common conditions developed

NHS Highland Respiratory MCN

Extended Community Care Team MDT: Primary, Community & Secondary CareFocus on Inpatient / Recently Discharged / High Risk

IndividualsDirect Spot Purchase of Home Care ProductsLocal Care Home Beds (2)

Outcomes:↓ LoS by 2.6 to 3 Days↓Bed Occupancy by 19 to 25% No Change to Admissions

NHS Highland Respiratory MCN

LES: Anticipatory Care Patient Alert: completed in PC with patient & familyVulnerable Patients List

SPARRA Data & Local Knowledge1% most vulnerable at risk of admission Care Home Patients

Outcomes: 5,329 ACPAs developed across NHS Highland↓ 29% New Admissions ↓ 47% Bed Occupancy

Comparison of Emergency Inpatient/Daycase New AdmissionsBefore and After ACPAs

-

100

200

300

400

500

600

700

Before After Before After Before After Before After Before After Before After Before Before After Before After

Badenoch &Strathspey

Caithness East Sutherland Inverness Lochaber Nairn & ArdersierNorth WestSutherland

Ross & Cromarty Skye & Lochalsh

New

Adm

issi

ons

New Craigs

RGH

Raigmore

Community

CHP Name (All) Type EMERG New Admission? New Admission Died During Analysis Period No Match to Sparra Control (All)

Count of New Admission?

Locality Name Before or After

Type of Hospital

NHS Grampian Respiratory MCN

Staywell (Peterhead) Patient Education & Monitoring Software Anticipatory Care Plans OOH NotificationsMedicines Management NIV (when indicated)Hospital @ Home / Assisted Discharge

Community Bases PR (Aberdeenshire)

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)

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)

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 DaysReduction in Home ExacerbationsReduction in Urgent GP CallsReduction in Associated Primary Care Costs Patient & Carer Satisfaction

CREWS Equipment

Score 0 1 2 3 4 Total

Oxygen Saturation %

93% or above with air /oxygen

91-92% with air or oxygen 88- 90% with air/oxygen 80-87% with oxygen Less than 80% with oxygen

Pulse rate Less than 90 90-100 101-110 111-129 More than 130Temperature 35-36.9 37-37.5 37.6-38 >38°C with paracetamol

and antibiotic for 24hrs>38°C with antibiotic

for 3 days

Cough No cough/no change in cough

Increased cough but no sputum

Increased cough with sputum

Frequent coughing with sputum

Severe cough /unable 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 swelling

None Mild – in feet and ankles only

Moderate- in calves as well as feet

Severe – up to knee level Very severeabove knees

Shortness of breath/MRC

score

Not breathless/except on strenuous exercise

Short of breath when hurrying of walking up

slight hill

Walking slower than on level ground because of breathlessness, or stop for breath when walking

at own pace

Stops for breath after walking about 100 m or after a few minutes on

level ground level

Too breathless to leave the house, or

breathless when dressing or dressing

Daily Activities Fully active/Usual activity when

well

Cannot carry out heavy physical work, but can do

anything else

Up and about more than half the day; can look after yourself, but not well enough to work

In bed / sitting in chair for more than half the day;

need some help in looking after yourself

In bed or a chair all the time and need a lot of looking after

TOTAL

Adapted from Respicard ®

Usual Score when Well = Score when Unwell: Action: Contact Number for Respiratory Nurseif 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

Copyright (c) 2010 Phyllis Murphie and Helen Coles of Dumfries and Galloway Health Board

NHS Lanarkshire Respiratory MCN COPD Whole System Service

Outreach SpirometrySelf-management & Pulmonary RehabilitationRespiratory Home Support Service

Respiratory ESDLTOTSupportive & Palliative Care

COPD Telehealthcare Pilot Asthma Self-management Plans (Paeds & Adult) Asthma Transitional Care Pathway COPD Action Plan

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 1028 Days: 4 to 9 / 6 to 790 Days: 11 to 20 / 14 to 17

COPD Telehealthcare ProjectOutcomes Data for all 4 GP Practices

0

2040

60

80

100120

140

160

No's

bas

ed o

n a

tota

l of 3

8 pa

tient

s GP Audit 01/04/07 - 31/03/08

Project period from 15/09/08-25/01/2010 (incorporates one yearof data per practice)

Outcome Measures:

Outcome Median p-value

Hospital Admissions

1 vs. 0 <0.001*

Home Medication (Antibiotics/Steroids)

0 vs. 2 <0.001*

GP Visits 3 vs. 1 0.23

A&E Visits 0 vs. 0 0.14

*Statistically significant

Two Sides of the Same Coin:

Stakeholder Stakeholder Objectives Objectives

Corporate Corporate Objectives Objectives

Outreach SpirometryOutreach Spirometry HEAT: H6, E4, E5, E6, E7, A10, T10HEAT: H6, E4, E5, E6, E7, A10, T10

LTC: Anticipatory Care LTC: Anticipatory Care

Patient Experience Patient Experience

Self-management & Self-management & Pulmonary RehabilitationPulmonary Rehabilitation

HEAT: H6, E5, E6, E7, A10, T6, T8, T10HEAT: H6, E5, E6, E7, A10, T6, T8, T10

LTC: Self-managementLTC: Self-management

Patient Experience Patient Experience

Respiratory Home Respiratory Home Support ServiceSupport Service

HEAT: H6, E4, E5, E6, T6, T8, T10, T12 HEAT: H6, E4, E5, E6, T6, T8, T10, T12

LTC: Self-management, Anticipatory LTC: Self-management, Anticipatory Care, Care Management Care, Care Management

Patient ExperiencePatient Experience

COPD Telehealthcare COPD Telehealthcare HEAT: H6, E5, E6, T6, T8, T10, T12HEAT: H6, E5, E6, T6, T8, T10, T12

LTC: Self-management, Anticipatory LTC: Self-management, Anticipatory Care, Care Management Care, Care Management

Patient Experience Patient Experience

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

Questions