Coordinating value based care for Londoners with COPD and asthma

1. Coordinating value based care for Londoners with COPD and asthma Dr Louise Restrick, Co-lead LRT Integrated Consultant Respiratory Physician Whittington Health & NHS Islington

2. 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

3. What do patients & families tell us about their needs… ‘I don’t want to die’ ‘breathlessness is frightening and disabling’ ‘hospitals and GPs don’t talk to each other enough’

4. Language: Fear … and Hope and aligning agendas • Patients’ concern is breathlessness… • Frightening • Clinicians focus • on respiratory failure • Frightening

5. Value Framework Health Outcomes Patient defined bundle of care Value = Health Outcomes Cost of delivering Outcomes Cost Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

6. 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

7. Respiratory teams committed to care delivered with KREDIT* Kindness Respect Empathy Dignity Interest TRUST Approach to patient care and team work ... eg Schwartz Rounds *Whittington Health, London Respiratory Team and …

8. Londoners dying from smoking Respiratory Disease Cancer Cardiovascular disease Mental illness ‘1 in 5 deaths due to smoking’

9. COPD ‘Value’ Pyramid

10. The low value pyramid? Representation based on national GP contract data and locally retrieved data

11. Tools for coordinating value care: CCG dashboards - Tower Hamlets 40% smoking prevalence in people living with COPD

12. Tools for coordinating value care: CCG data - Islington

13. Tools for co-ordinating value care: Systems & Quality Improvement NHS Innovation Challenge Awards 2012 Local Enhanced Services: COPD & Quit Smoking GPs Academic Health Science Centres & Networks Practice Nurses Earlier Diagnosis

14. Tools for coordinating value care: National COPD Audit 2010 ERS Audit

15. 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

16. Changing how we think about smoking ‘Smoking kills, stopping works’ Sir Richard Peto 2012 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…

17. Why do Londoners with emergency respiratory admissions need co-ordinated value care? • 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 Respiratory Pharmacist 64-71% re-admissions different reason* *Krumholtz NEJM 2013;268:100-102

18. Tools for co-ordinating value care: COPD Discharge Bundle Developed by CLARHC Hopkinson et al Thorax 2012:67:90-92

19. Co-ordinating value care: Quit smoking advisors working with sick smokers as in-patients ~500 smokers with severe COPD* 10 intensive interventions with medication 44% quit at 6/12 with NRT 60% quit at 6/12 with varenicline CQIN Clinical Lead BTS Champion Pharmacist *Jiminez Ruiz et al Nicotine and Tobacco Research 2011

20. COPD Discharge Bundle Developed by CLARHC Hopkinson et al Thorax 2012:67:90-92 Co-ordination not easy!

21. Co-ordinating value care: Respiratory Physiotherapists ‘Breathe Better, Feel Good, Do More’’ Pulmonary Rehabilitation

22. Tools for co-ordinating value care: behaviour change & motivational interviewing skills

23. Co-ordinating value care: psychologists in & working with respiratory teams Respiratory Team Psychologist

24. Tools for co-ordinating value care: CQINs

25. Co-ordinating value care: Respiratory Nurse Specialists In-patient Respiratory Nurse Specialist Community Respiratory Nurse Specialist

26. ‘Hospitals and GPs don’t talk to each other enough’ Why aren’t we speaking to GPs on admission? Why aren’t we connecting patients with their GP? Why aren’t we speaking to GPs at discharge? More than 1 in 6 people admitted to hospital had not seen their GP in the previous year

27. 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

28. Enhanced Recovery Occupational Therapist Social Worker Care planning conferences … Shared decision making: agreed shared agenda Identify & address treatment and care gaps & needs Hospital & MH Social Worker Consultant Psychiatrist Mental Health Key Worker Quit Smoking Advisor … with patients & family

29. Tools for co-ordinating value care: coordinate my care COPD template

30. My team or I can lay hands on … • Apulsoximeter . Acontact for someone who can use a spirometer . ACOPD/asthma action plan . A range of quit smoking products . A spacer .Stories and testimonies about PR .Registersof people with asthma, COPD, their smoking status and those at the end of life . An ICS safety card . Adischarge bundle.LRT and Impressproducts .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

31. ‘Care is only integrated when people want it to be, otherwise it does not happen …’ * *LRT feedback from Londoners living with COPD 2013

32. Coordinating value based care for Londoners with respiratory disease ... Kindness Respect Empathy Dignity Interest TRUST …not only clinicians who make it happen