Pathway for COPD patient in Wolverhampton 2011

1. Pathway for COPD patient in Wolverhampton 2011 Tele- medicine Oxygen service Therapies inc pulm rehab Case manager/ Community Matron Respiratory Physician Palliative care COPD Patient and carers A&E Hospital at home team EAW/General Physician Social Worker GP Practice nurse Intermediate care team Ambulance service Disjointed, duplication Wasted resources Poor pathways of care Patient not seen in most appropriate place

2. Integrated care pathway Prevention Early diagnosis Treatment Communication Self care Education Partnerships of care Specialist review Convenient follow up Palliation Patient Integrated care system Chronic care model Good use of resources Robust pathways Patient seen at appropriate place

3. No more silos • Rainbow feeds into DDG • Commissioner present at monthly meeting • Robust data feed • New Cross manager integral part • Chief operating officer sponsors lung improvement program

4. Respiratory In Reach • 7 day service • Consultant led but multidisciplinary • Potential benefits • Reduced length of stay • Improved diagnosis – coding and triage • Better initial treatment • Improved mortality • Standardised discharge bundle - reduced readmission rate • Improved patient experience.

5. OPEN ACCESS TO HOT CLINIC Respiratory Centre New cross Hospital (Monday to Friday only) To arrange an urgent appointment. phone before 11am If your respiratory condition deteriorates Telephone 01902 695061 HOT Clinic • Innovative • Consultant delivered daily admission avoidance clinic • Open access including self referral • Conversion rate currently < 15% • But…….? timely

6. MDT • Fortnightly multidisciplinary meeting • 30 day readmissions discussed + open access for all members of RAINBOW • Primary care represented through community matrons • Palliative care consultant and CBT trained physiotherapist in attendance • Actions plans produced and communicated

7. Community clinics • Clinic delivered in heart of high prevalence area (low DNA rate) • Improved understanding of issues facing GP’s (and vice versa) • Raises respiratory profile and builds credibility of RAINBOW in general practice • Facilitates finding the missing millions

8. Other services in place for COPD patients • Well established and efficient HOSAR • Hospital at Home • Quality assured spirometry • GPWSI • Pulmonary rehabilitation in 4 areas

11. p = 0.11