Integrated respiratory care “It’s not what you do, it’s the way that you do it”

1. Integrated respiratory care“It’s not what you do, it’s the way that you do it” Irem Patel Consultant Respiratory Physician, Integrated Care King’s Health Partners Lambeth and Southwark CCGs

2. My background • SE Thames Respiratory and GIM Training Programme • PhD: COPD epidemiology and airway cell biology, London Chest • Flexible trainee • 2009: First substantive Integrated Respiratory Consultant post in UK; Imperial College London , H&F PCT • 2013: Integrated Respiratory Physician, Kings Health Partners, Lambeth and Southwark CCG

3. My experience in West London.....

4. Consultant in Integrated Respiratory Care: Responsibilities (1) • promote integration of respiratory care between primary and secondary care • provide medical leadership for the current integrated services with a special reference to the community respiratory assessment unit (CRAU), the oxygen assessment service, pulmonary rehabilitation and medical support to the respiratory nursing team (including TB specialist nurses within the community). • support spirometry services in the community for practices which wished to provide their own service, rather than utilise CRAU and to ensure that standards of spirometry were adequate in terms of health and safety issues and interpretation of results • help in the selection of patients for pulmonary rehabilitation and to lead in the development of services for pulmonary rehabilitation in the community

5. Consultant in Integrated Respiratory Care: Responsibilities (2) • provide medical leadership to the COPD admission avoidance and early discharge schemes, and to act as a link between the acute hospital COPD services and the nursing team • act as a learning resource for primary care physicians, practice and district nurses and community matrons • trial and evaluate outreach clinics (place of work teaching) and a community-based consultant clinic • assess and manage patients with complex breathlessness in the community, liaising where appropriate with the cardiac services • work with others to promote better end of life care for those with severe lung disease • work with others to develop advanced respiratory support in the community for those needing home ventilation

6. Shape of Post • 100% funded by PCT • 70/30 split weighted to community – how to quantify? • 30% secondary care - backfill into community by other colleagues

7. Background 185,000 population 28% adult smoking prevalence 1% COPD prevalence (modelled 3.7%) 49% mod-sev deprived

8. 32 GP practices 5-6 networks by 2012 4 acute hospitals (CXH, HH, SMH, CW) 1 community provider Context Network 1 3002* 30 Network 2 3845 7 1741 Network 3 5/21/26 31 12600 /2 Network 4 3526 6084 16 3 Network 5 4887 20 20 4388 1 No Network 11195 24 5835 28 10397 15 7605 4639 23 9 4049 25 10012 29 9615 11 13706 27 3002* 30 8142 4 3348 13 1939 12 1776 22 6910 12886 14 19 3534 8 7448 10 3877 9340 18 2 9556 6/17

9. Process • 2009: Gap Analysis • 2009/10: Optimal Service Model and Respiratory Redesign – GP chair • 2010/11: Integrated Specialist Respiratory Service commissioned by H&F PCT • 2010/11: Consultant led “team without walls” across acute and community providers • Co-located acute and community team (one team) • 2010/11: Lung Improvement Projects

10. Smoking cessation, health promotion and self care Primary prevention Health promotion and education Secondary Prevention: Accurate diagnosis Spirometry screening of high risk patients in community and general practice Accurate performance and interpretation of spirometry (ongoing assessment of competencies with support) COPD register (Ongoing validation with support) Stratification of registers by disease severity: mild, moderate, severe Enhanced referral pathways to specialist support for diagnostic difficulty Community Pulmonary Rehabilitation General Practice Tertiary Prevention: Treatment andmanagement of stable disease Expanded Templates to guide NICE guideline based management Vaccination Named specialist respiratory nurse for practice clusters Specialist medication reviews by community pharmacists Self management education and written individualised action plans Anticipatory care Knowledge and support for carers Enhanced General Practice and community specialist services Complex / severe disease Case management by appropriate case manager (respiratory nurse specialist or Community Matron) Evidence based oxygen prescribing and follow-up Consultant and nurse led clinics with MDT support (including physiotherapy, psychology, dietetics) Non Invasive Ventilation Planned hospital admission for those who need it Co-ordinated social care Specialist and generalist community, hospital and OOH services Unscheduled care Admission avoidance through intermediate care Hospital admission Supported discharge to reduce LOS via EDS programme or intermediate care Post admission review in consultant and nurse led clinics Supportive and palliative care Specialist and generalist community and hospital End of life care Gold Standards Framework Prognostic indicators for primary and secondary care Specialist support Referral pathways Treatment and management Admission avoidance Education and clinical support Information and Clinical Audit H&F Integrated Respiratory Service: COPD Pathway

11. Service Developments Consultant support to community RNS team Community MDT Community based Pulmonary Rehabilitation COPD Discharge Bundle with community follow up Early/Supported Discharge Community consultant clinics and virtual clinics Specialist support to primary care Respiratory training for community HCPs Community sputum clearance and respiratory physiotherapy

12. Challenges • No road map • Learning curve community service provision local population commissioners service development • Not just a COPD doctor • Balance of emphasis – traditional versus community role: CPD, colleagues, mentorship

13. Challenges • Governance • Infrastructure • IT • Perverse financial incentives • Aligning agendas of different organisations • Culture of “one team” • Change management • Challenge of measuring

14. Value? Hilary Pinnocket al, BMJ 2011; 342 COPD: • A story with no beginning……… • A middle that is a way of life…… • An unpredictable and unanticipated end an opportunity to make a difference to the whole story – for a population

15. Value? Lower spend Higher spend Lower spend Higher spend Better outcome Better outcome Better outcome Better outcome Reducing Variation Value Based Care Right Care 4 2 10 24 14 25 19 5 9 27 31 13 15 16 20 3 30 29 17 8 11 12 6 18 1 23 7 21 22 26 28 Lower spend Higher spend Worse outcome Worse outcome

16. “a continuum of patient centred services organised as a care delivery value chain for patients with chronic conditions…… ….optimal daily functioning and health status for the individual…”

17. Value? an opportunity to support and quality assure coordinated care – for a population

18. Value? Colleagues - community • Education and training • Accessibility • Communication • The human face of the hospital! Colleagues – hospital • Confidence in pathway • Improved inpatient processes

19. Why I am (still!) an integrated physician “ We are living in a golden age of medicine.. ……..and something similar is happening in the world of healthcare” Prof Tom Lee Harvard Improving outcomes for patients Learning new skills - for a LTC clinician Personal satisfaction Patients and colleagues Research