AN INTEGRATED APPROACH TO IMPROVE PATIENT FLOW A LOCAL EXPERIENCE Kathleen McGuire LTCC Management Lead Febru

2. Why COPD? Over 8500 people currently diagnosed in A&A Probably another 8000 undiagnosed Commonest reason for acute and recurrent admission in older people COPD admissions rising especially for women and deprived postcodes Number of bed days reducing but not for women

3. What does it take?

4. Improvement Actions for Complex Care Stratify population and identify those at high risk Target and deliver a proactive Case/ Care Management Approach Introduce advanced/anticipatory care plans Communicate and share data across the system

5. PATIENTS AT HIGH RISK OF HOSPITAL ADMISSION

7. What we wanted to achieve Quality Enhanced Service- general practices signed up to reviewing SPARRA listsRegular MDT review and care planning along with DN team of relevant patients Notification to OOH and Acute Hospitals of relevant patients Introduction of ACP into electronic notification Reduce emergency admissions

8. In addition for COPD patients Quarterly review of highest risk patients Encourage use of self-management plans Review of all emergency admissions Consideration of pulmonary rehabilitation

10. Success?Short(ish) term outcomes Staff Engagement Desire for improved communication Desire to improve integration between hospital, community and social care SPARRA becoming a trend with hospital staff A belief in new collaborative ways of working

11. Steps Identified all new Stakeholders Workshop to map patient pathway and identify bottlenecks Identification of Patient Flow Benefits mapping and realisation workshop Risk Management and mapping Cost benefit analysis Use of Logic Model

16. PATIENTS AT HIGH RISK OF HOSPITAL ADMISSION & RE-ADMISSION

17. Examples of Service Improvement Audit of MDT Audit of ACP Notification PDSA work with individual practices PDSA in hospitals PDSA in Out of Hours Supported staff to champion LTC Marketing and Communication Significant Event Analysis Individual Care Planning

18. SPARRA PATIENT FLOW Does the patient have a Hospital Notification Form Yes No If no, why not? Not printed in A&E  Not entered/referred by GP Practice Other _____________________ If not entered by GP contact and request SCI Gateway referral made. Agree PDSA with practice If not printed in A&E, identify with admitting clinician, request print of and agree PDSA If HNF in ward. Did the admitting nurse contact the care co-ordinator? Yes No If no, admitting nurse to contact care co-ordinator and agree future PDSA Did care coordinator contribute to discharge planning? Yes No If no contact LTCC District Nurse Liaison, who will agree future PDSA Did the admitting nurse identify EDD? Yes No If no admitting nurse to identify EDD and agree future PDSA If patient COPD or Heart Failure have specialist services been notified?  Yes No If no, specialist services to be notified and agree future PDSA

20. NHS Ayrshire & Arran Long Term Conditions Collaborative SPARRA Scottish Patients At Risk of Readmission and Admission What do I do with a patient who is on the SPARRA list? You will know if a patient is on the SPARRA list, as a Long Term Conditions Notification Form will be attached to the patient�s admission notes from A&E Contact the Co-ordinator of Care (details on eHNF) to let them know that the patient has been admitted. Ascertain how the patient normally manages at home, their normal condition and details of their anticipatory care plan How does the patient self manage their condition, do they have a self management plan Ask if they have a care package at home. This patient must have an EDD Invite the co-ordinator of care to your Multidisciplinary team and involve in Discharge Planning as soon as patient is admitted Contact hospital home care/social work team ask if care package was meeting patients� needs before admission. Note on white board this patient is on the SPARRA list by drawing a red triangle beside their name. If any problems with discharge planning contact discharge co-ordinator. Leaflets are available on all wards or by contacting the Discharge Co-ordinator/Facilitator or Bed Managers.

25. Success - 2 Years Down the Line? Better understanding of various roles to support COPD & the costs of same Closer alignment of health and social services for COPD support Organisations that support self-management at every opportunity � across integrated health & social care systems/pathways Commissioned services for self-management support across health & social care systems

26. To identify mechanisms that will enable resources to follow the patients to support self management along the pathway To consider options of extending to other Long Term Conditions Integrated Resource Framework Project

27. What might this look like? Pooled budget for home care support to provide short term/additional care during exacerbation of COPD Home carers with additional training in self management support and respiratory care Community Pharmacy support for COPD patients & their carers Specialist community based clinical support as required � specialist nurse, consultant et al Self management training for paramedics and ambulance staff Awareness of self management within hospitals