NHS Outcomes Framework 5 Domains

2. NHS Outcomes Framework5 Domains • Prevent premature death • Quality of life for people with LTC • Recovering from ill-health • Positive patient experience • Patient safety

3. Outcomes Strategy - objectives Respiratory Clinical Pathway Team • Improve respiratory health and minimise inequalities • Reduce numbers developing COPD, importance of lung health, understand and avoid or minimise risk factors • Reduce premature deaths from COPD pro-actively: early identification, diagnosis and intervention at all stages of the disease • Enhance QOL and patient experience through to EOL • Ensure safe and effective care, minimise progression, enhance recovery, promote independence • Asthma: Free of symptoms by prompt and accurate diagnosis, shared decision making re Rx, self-management, reducing unscheduled care and risk of death Working together to improve respiratory care in the North West

4. Outcomes Strategy Respiratory Clinical Pathway Team Respiratory health & good lung health Early accurate diagnosis Active partnership between HCPs and patients Chronic disease management Tailored, evidence-based Rx for the individual Working together to improve respiratory care in the North West

5. NICE Quality Standards Respiratory Clinical Pathway Team • Symptoms recorded, diagnosis confirmed QA spirometry • Individual comprehensive management plan including information • Rx as per NICE guidance • Regular assessment • Smoking cessation • Pulmonary rehabilitation • Exacerbation management plan & rescue pack • O2 assessment by specialist team • O2 review as part of integrated care • Admissions cared for by respiratory team • NIV services • Post-discharge review within 2 weeks • Palliative care Working together to improve respiratory care in the North West

6. How many COPD patients have NO co-morbidity?

7. Finland 10yr program Respiratory Clinical Pathway Team • Smoking cessation • Reduced bed days • Spirometry QA • Multidisciplinary structure • Respiratory clinical leadership • Trust and rely on 1y care Kinnula. PCRJ 2011 Respiratory Clinical Pathway Team

8. Dementia and inhaler use • Compliance with therapy (self) • MMSE > 24/30 – usual therapy • MMSE 20-23/30 – may manage inhaled therapy • MMSE <20/30 – unable to manage • Symptom recognition • Susceptibility to Delirium Allen SC et al Age and Ageing 1997

9. Respiratory Clinical Pathway Team Diagnosis Register Education Appropriate treatment Monitor Working together to improve respiratory care in the North West

10. Early diagnosis & treatment Annual cost of treatment for COPD patients

11. Random question: • “What’s the most successful inhaler device and drug ever mass produced?”

12. Registers can tell us a lot • Prevalence and accuracy of diagnosis • Severity – and treatment • Poor control - exacerbation frequency (including monitoring OOH and admissions) • Functional disability - MRC and RCP 3 questions • Presence of co-morbidities • Exception coding • Identifying high risk groups and targeting treatment

13. EoL COPD Trigger tool • Severe (FEV1 <50%) or very severe COPD (FEV1 <30%) • Frequent exacerbations ( ≥3 acute exacerbations in the last 12 months especially if associated with hospital admission • Need for NIV • Unremitting symptoms despite maximal therapy • Dependence on oxygen • Co-morbidities Consider refer for palliative assessment and addition to GSF register NHS Salford 2010

14. CCG reports(COPD)

15. Practice(reviews)

16. Exceptionreports

17. Discussion • How can we identify COPD patients at high risk of admission? • How do we drag this information kicking and screaming out of our clinical computer systems? • Then what do we do about it?

18. Audits • “Missing millions” • Age >35, smoker or ex, chest inf/Abx/pred L12m • MRC 3 or above • Referred for Pulmonary Rehab? • Triple Rx (ICS, LABA & LAMA) • Had smoking cessation, flu jab, considered for PR? • Exceptions from QOF? • Prevalence of COPD increasing?

19. Identifying those at high risk of admission • Severe disease (FEV1 <30%) • On long term oxygen therapy – or who need LTOT and have not got it • Older age groups (aged >75yrs) • Reduced mobility / physical activity • Co-morbidities (IHD, CHF, diabetes, depression, anxiety) Garcia Americh Thorax 2006 and 2008

20. Identifying those at high risk of admission • Previous unscheduled admissions • Frequent admitters 60% risk of further admission vs 10% risk in those having first admission • Previous exacerbations – predict future exacerbation • Check for prescriptions of antibiotics and/or oral corticosteroids issued to people on COPD register AND anyone aged over 35 years, smoker or ex-smoker who has presented with a chest infection in L12m • 85% of COPD admissions had no previous admissions DH 2010, Wedzicha 2011

21. Self management support – will one size fit all? • To be activated to be effective self managers our patients require a high level of knowledge skills and confidence • Around 40% of patients are likely to need additional support to self manage successfully • By increasing activation step by step our patients can experience small successes and steadily build confidence in their ability to self manage Hibbard et al Health Serv Res 2005 Hellmans M abstract PCRJ 2012

22. NICE guidance Breathlessness and exercise limitation SABA or SAMA as required* FEV1 ≥ 50% FEV1 < 50% Exacerbations or persistent breathlessness LABA LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness LABA + ICSin a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler * SABAs (as required) may continue at all stages Offer Consider

23. COPD – Holistic treatment?

24. Pulmonary Rehabilitation • % of COPD population referred? • % drop out rate? Troosters et al ERJ 2010; 19: 24 - 29

25. Are we referring for oxygen assessment appropriately? • A lifesaver for some • A killer for others • Same Rx for all? • Local HOS & HOOFs? • Pulse oximeters?

26. Questions: • How can we identify patients with COPD approaching end of life? • Do we have COPD patients on our GSF list?

27. Discussion • What was good about the consultation? • What could have been done better? • What might you do differently next time? • How did we do for QOF here? • (Was this a doctor or nurse?)

28. Aims Respiratory Clinical Pathway Team • Uniform high level standards of care • Positive patient experience • Confident commissioning of effective services Respiratory Clinical Pathway Team

29. Integrated care?

30. Right Care • Doing the right thing • Doing things right • (In the right place at the right time) • Generic vs disease specific model • Consistent messages – do patients care if it’s called primary, secondary, etc?

31. Don Berwick (NHS 60) • Patient at centre of everything “Nothing about me without me” • Clinical leadership at the core, patients need integrated journeys … assessment, assurance and improvement of quality • Don’t put your faith in market forces … competition becomes toxic • Avoid supply driven care like the plague • Aim for Health (the NHS’s middle name)

34. NW Inhaler technique project • 7 PCTs / CCGs • Innovation fund • Local videos filmed • Real HCPs and patients • 300 Pharmacists trained • Hospital staff mandatory training • GPs and PNs • Patients • http://wires.wessexhiecpartnership.org.uk/video-series/inhaler-technique/

35. Patient Passport • Brings together: • NICE guidance • Outcomes Strategy • Companion document • Quality Standards • Patient Voices Top 10 • Patient held

36. Walk the 7 steps to the best COPD care I have COPD: • I have had my diagnosis confirmed by lung function test performed by a qualified person • I feel supported to manage my COPD. I am actively involved in my care and have the opportunity to discuss how I wish to be treated • I have been offered help and support to stop smoking • I know the importance of keeping active and offered the opportunity to improve my activity through exercise and pulmonary rehabilitation if appropriate • I know how and when to take my medicines, and feel able to use my inhalers and other medicines properly • I have a written action plan, rescue medication and know when and how to use them • I see my doctor or nurse routinely at least once a year for review of my lung function, medicines and inhaler technique, breathlessness, activity and oxygen levels, flu vaccination and my action plan