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Providing Early Supported Discharge and Anticipatory Care; a Community Nurse model

Grampian COPD MCN. Providing Early Supported Discharge and Anticipatory Care; a Community Nurse model . Small I (1) , Powell I (1) , Brown D (2) , Wilson E (2) , Strachan M (3) , Christie G (3) . . Grampian Respiratory MCN Peterhead Health Centre Aberdeen Royal Infirmary. Introduction.

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Providing Early Supported Discharge and Anticipatory Care; a Community Nurse model

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  1. Grampian COPD MCN Providing Early Supported Discharge and Anticipatory Care; a Community Nurse model Small I (1), Powell I (1), Brown D (2), Wilson E (2), Strachan M (3), Christie G (3). Grampian Respiratory MCN Peterhead Health Centre Aberdeen Royal Infirmary

  2. Introduction • Early Supported Discharge schemes have been shown to be effective in reducing the length of hospital stay of patients with COPD(1). Although they are becoming increasingly common, there are logistical difficulties in delivering this type of care in a peripheral or rural setting. In this presentation we describe one model that uses an existing Community Nurse Team to deliver such care, and the expansion of this service into patient education, anticipatory care, exacerbation management and hospital avoidance. • Peterhead, the site of the pilot, is an industrial market town with a population of approximately 20,000, managed by a single, large General Practice with on site (24 bed) Community Hospital and A&E department

  3. MethodEarly Supported Discharge • QOF returns for Aberdeenshire North were used to establish the number of patients in the area with COPD. Previous audit work had identified the number of patients with severe disease. • On this basis, a business case was developed, adding 0.5 of a Band 5 Staff Nurse to the existing Community Nurse complement in Peterhead, to deliver ESD in the community. • All members of the community team attended 2 half day training and education sessions run by clinicians from the MCN. • The Community Nurse Team Leader and identified project co-leads work shadowed the existing ESD team in Aberdeen Royal Infirmary, and a referral pathway between the two was established. • A patient education and monitoring software package (Staywell)(2) was introduced and adapted to provide baseline information on the level of disease specific knowledge of patients with COPD and their carers.

  4. MethodAnticipatory Care • Adapted from BODE(3), and SPARRA(4) data, a search of patients on the Peterhead Practice COPD register was performed using a series of VISION searches, together with individual case record analysis. Patients with any one of the following criteria were included as ‘likely to benefit from the anticipatory care service (ACS)’. • Patients were assessed using the Staywell software application, and an individual and personalised anticipatory care plan generated, discussed and agreed. • Practice clinical and management staff established a rapid access system for ACS patients. This includes organising additional therapy (antibiotics, corticosteroids, nebulised therapy and oxygen), additional social care and medical follow up. An out of hours patient alert is generated, highlighting the patient’s clinical status, and the option of community hospital admission, should the patient’s condition deteriorate.

  5. Criteria for Recruitment into COPD Anticipatory Care Service • Spirometry confirmed Diagnosis of COPD • Any one of the following; • Previous contact with ESD team • FEV1 <30% predicted • QOF exception coding due to severe disease • Any method of domiciliary Oxygen provision • 2 or more admissions with COPD in previous 12 months

  6. Progress to date • 35 patients have been recruited to the pilot • Staywell Exacerbation Plans have been agreed between patients, carers and DN • Patient records and repeat prescriptions have been updated in alignment with SEP’s.

  7. Discussion • This pilot has not been running for long enough to have provided statistically robust data. Initial feedback from patients and staff has been positive. • A formal evaluation is established. • Staff have taken on this additional role enthusiastically and competently. There have been some problems, particularly around gaining rapid access to GPs. Achieving universal adoption of newly established clinical protocols is also challenging. • The potential risk to patients of ‘too easy access’ to antibiotics and steroids has been acknowledged. Ongoing regular case based MDT meetings should reduce the overall risk to patients of drug exposure, mis-diagnosis and failure to initiate timely palliative measures.

  8. Conclusions • Early Supported Discharge can be safely delivered by a Generic Community Nursing team with appropriate clinical education and support. • Assessment of patients’ knowledge and needs can be achieved using an adapted Staywell template. • Anticipatory care services can be delivered using a Generic Community Nurse team.

  9. References • (1) Intermediate care—Hospital-at-Home in chronic obstructive pulmonary disease: British Thoracic Society guideline. Thorax 2007;62:200-210 • (2) www.intouchwithhealth.co.uk/self_care_COPD • (3) Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005–12. • (4) www.isdscotland.org/isd/files/SPARRA

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