Hospital at Home: Transforming COPD Care

2. Trust Member Event Wednesday 21 June 2017 Hospital at Home Dr Catherine Monaghan Belinda Peckett Amy Wynne

3. Hospital at Home • Background to the service • Patient journeys • Key Performance Indicators • Added value • Where next • Patient experience

4. Hospital at Home • MDT delivered, consultant led service • Delivers care at home for patients with exacerbations of COPD across the CCG • Provides a full package of care tailored to an individuals’ needs • Offers both early supported discharge and admission avoidance

5. Background • Hospital Admissions for Exacerbations of COPD (Per 1,000 COPD Registers): 146.9 • Mean Length of Stay in Hospital for COPD interventions: 5.94 days • Cost of Hospital Interventions for Exacerbations COPD (£ Per 1,000 COPD Registers) : £ 298,164 • approx. £2.2M spend per year

6. Background • Hospital Readmissions within 30 Days: 20.6% • Emergency admissions are increasing year on year: • 780 in 2005/6 • 1,000 in 2012/13 • 1151 in 2015/16 *Data collected from NEPHO 2013

7. During an acute admission • Patients do not necessarily see a COPD specialist • There is evidence of deconditioning and loss of muscle mass • Admissions are not necessarily good for patients • Psychological detriment to patient

8. Hospital admissions with COPD • Why do patients need to be admitted: • If they are seriously unwell and need emergency oxygen or ventilation • Why are patients admitted when they don’t need to be: • Because there is (was) no alternative

9. Hospital at Home • Offers a serious alternative to an acute admission • Provide acute care at home for patients with exacerbations of COPD • Consists of a multidisciplinary team of experienced health care professionals • doctors, nurses, physiotherapists, HCAs • Service available 8am-8pm 7 days/week

10. H@H • Referral criteria: • Known COPD • Increased SOB • Increased sputum • Increased cough

11. Exclusion criteria • • Unconfirmed diagnosis of COPD• New Hypoxia with SaO2 <88% on room air• New or worsening oedema• Acute confusion• Impaired level of consciousness• Central Cyanosis• Respiratory rate >24 • • Pulse Rate >125bpm• Significant chest pain• Hypotension BP <90/60 • • Rigors

12. Referrals • Referrals accepted from different health care professionals: • GP • Community matrons • Accident and Emergency • NEAS • Acute trust • Rapid response

13. Self referral • Patients can self refer if they have already been through the service

14. How to refer • Fax referral to SPA • Phone SPA • SPA then task the team directly • Patients can phone the SPA and self refer into the service

15. What the service offers • A home visit within 2 hours of referral being received • Comprehensive assessment by a professional with expertise in COPD • An individual Programme of care tailored to each patients specific need

16. What the service offers • Support and care at home • Medical interventions; • Nebulisers • Antibiotics • Steroids • Chest physiotherapy • Sputum clearance techniques • Symptom management • Inhaler advice and technique • Medicines management

17. Every patient is offered: • A full review of treatment • Advice on smoking cessation • Referral to pulmonary rehabilitation • A written plan as to how to self manage their COPD • A six week consultant follow up review • A phone number to call if they become unwell again • Signposting to other services: D/N, palliative care, Dietician

18. Safety • Access to a respiratory consultant 9am to 5pm Monday to Friday for advice • One hour per day of rapid access slots with a respiratory consultant • A weekly MDT • A six week follow up appointment

19. Patient Journeys Dorothy T

20. Dorothea W

21. Gloria

22. What our patients receive • Comprehensive assessment from respiratory practitioners with advanced respiratory skills. • Treatment prescribed and issued in accordance with patients symptoms and clinical findings. • Weekly discussion at MDT

23. On going management and support from the team with no time limits, based on clinical need. • Multidisciplinary working, working along side other health professionals to make every contact count including close links with NEAS • High standard care delivered with compassion

24. Open and honest communication with our patients around disease management and disease progression. • Health education and promotion.

25. Pre service criticisms and our experience so far • “patients won’t like this, they want to be in hospital” • “this is potentially unsafe, what if a patient is really unwell” • “what if the diagnosis isn’t COPD?” • “you will get a lot of referrals for patients that don’t need to be in hospital” • “GPs won’t use this: its easier just to admit a patient”

26. Key Performance Indicators • Referrals received: 1684 • New patients seen: 1535 • Home visits: 5210 • Inappropriate referrals: 120 • Acute admissions: 60

27. Other data • Mean length of stay has reduced by 17% • Admission avoidance is difficult to measure exactly: • we think about 60% of the patients referred into our service would otherwise have been admitted • this leads to a 33% reduction in the number of admissions we would have expected

28. PDSA • PDSA in November 2016 • Between 8am-8pm every GP who wanted to admit a patient with COPD was asked if they wanted to refer them to the H@H team instead • We admitted zero patients with COPD that week from GPs

29. Referrals into service

30. Added value • Ensuring diagnosis is correct • Optimize medical treatment • Medication to reduce risk of future exacerbations • Optimize inhaler treatment • Making sure patients are on the best and most cost effective inhalers • Signposting to appropriate services

31. Patient experience Patient survey

32. Patient experience • Always helpful and never rush • Could not ask for better treatment • 100% better than being admitted to hospital • I have never known care like it • Best service I have ever come across • We need this team: I will never be afraid if I’m poorly

33. Summary • Refer all patients with an exacerbation of COPD who meet the criteria • Send referral via the SPA • Team will visit within 2 hours: 8am-8pm 7 days a week • We will provide a full programme of care

34. Patient experience • Patient experience Video • https://youtu.be/lYJjC5uol7A • Very powerful for campaign care closer to home for NHS England.

35. Where next? • Further work with NEAS • Strengthening links with GP practices • Doing practice visits and case reviews, at request of CCG • Expand the number of conditions we cover • bronchiectasis

36. Where else can we use this model? • Frail elderly • Nursing and care homes • Heart failure

37. Thank you