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A rapid response for COPD exacerbations

Dr Dan Bunstone and Helen Pressage explain how Warrington CCG has created capacity for rapid management of patients in the community who would otherwise have gone to hospital

Like many pilots in commissioning, our starting point was looking at what we could do to tackle the increasing number of hospital admissions.
In 2010, we were flashing red on the SHA’s screen as having very high admission rates compared with other areas and we were one of the highest admitters for COPD in the region.
We did a ‘deep-dive’ analysis of COPD hospital admissions, where several commissioning managers and clinicians looked at the data over a number of weeks to really draw out what was behind the headline figures.
This showed several things.
⦁ The number of patients presenting to A&E who were then ‘converted’ into an admission was very high.
⦁ A lot of patients were being admitted for between zero and two days.
⦁ A significant number of short-stays were for pneumonia – suggesting the condition was not, in fact, pneumonia, but was how the patient had been coded.
We also set up an interview with the Warrington Breathe Easy patient group – the local branch of the British Lung Foundation.
This gave really useful feedback on how to develop a better service for patients.
The Breathe Easy group told us the following:
⦁ Patients were often admitted even though this wasn’t what they really wanted. The risk of infection in hospitals scared them and they didn’t find their stay in hospital particularly comfortable or relaxing and would have preferred to be cared for in their own homes.
⦁ A number of patients felt they would have preferred to be at home but there wasn’t the support available in the community. One scenario described was a patient sitting all day in a hospital bed with someone coming round once to check they’d taken their antibiotics.
⦁ Patients were unclear how to access specialist advice when their condition went wrong. Often patients would go to the person or service they had gone to before – which was usually the hospital.
⦁ There was a sense among patients of having to ‘battle’ against the system to get the care they needed, at a time when they did not feel at their strongest

A new hospital alternative

At the time, the Department of Health’s Transforming Community Services policy was coming into effect and a decision was made by the PCT that rather than transfer our small existing community respiratory team, made up of 4.7 whole-time-equivalents, to the new community health trust, where the rest of our community services were transferring, we would integrate them with the acute trust’s respiratory team.
It was decided to initiate an additional two-year pilot at the cost of £180,000 a year to create a single point of access for patients and primary care, so more patients could be cared for at home.
The pilot funding has allowed us to increase the capacity of the integrated care team by five staff.
This is made up of: 
⦁ a new band 7 nurse to triage patients
⦁ a band 6 occupational therapist
⦁ an oxygen co-ordinator
⦁ two healthcare assistant/rehab assistant level roles to free up more skilled staff to concentrate on early supported discharge, admission prevention and more complex cases.
The hospital had appointed a consultant with a community COPD priority guide
All referrals to triage are categorised using a priority guide to enable appropriate response.
Priority 1 – same-day review
Patients are categorised as a P1 when they have an acute change in respiratory symptoms or are at end-stage disease with a change in symptoms.
Priority 2 – next-day review Patients are categorised as P2 when they have an acute change in respiratory symptoms but have been reviewed by the GP or other healthcare professional within the last 24 to 48 hours or if treatments such as rescue pack antibiotics and steroids have already been commenced.
Priority 3 – review within one week Patients are categorised as P3 when they have had gradual onset of respiratory symptoms (experienced over a period of two weeks or more).
End-stage disease referrals with no acute change in symptoms are categorised as P2/3.
The respiratory team also does a daily trawl of the acute admissions to identify any patients suitable for early supported discharge, any patients who are recurrently attending hospital or struggling with increased symptoms but not known to the Warrington Respiratory Team.
The priority guide was created with the consultants and shows clearly what should happen for patients at either end of the spectrum. But for patients in the middle it’s less clear cut whether or not, with our support, they can remain at home.


Same-day access

Based on the feedback from the Breathe Easy interview, we realised it was important to have an early and rapid response to a COPD exacerbation.
Before the pilot, everyone was working at capacity – so it was rare for same-day appointments to be available. Often by the time patients were seen by a clinician, their COPD had worsened and they needed an admission or patients had defaulted to their only other option – to turn up at A&E where they would probably be admitted.
We have worked with the hospital to leave a block of same-day appointments free every day as they have a number of nurse-led respiratory clinics at the hospital.
Patients access the new integrated respiratory team by calling a single number. The line is manned by the new band 7 nurse.
The line is open 8.30am to 5.00pm Monday to Friday. Referrals received after 4pm are generally seen the following day unless the patient is admitted overnight.
The nurse assesses patients over the phone and, if necessary, organises a same-day assessment by one of the respiratory team in the patient’s own home or arranges for the patient to access a same-day appointment at one of the free slots in the hospital clinic if they have the family support to be able to get to hospital.
Sometimes, though, no actual contact is needed and the patient or carer simply needs reassurance that they have done the right thing, for example started their emergency steroid pack.
Primary care can also call the number for advice about how best to manage and maintain a patient in the community. So it’s about that collaboration between primary care and the community so the default isn’t always secondary care admission.
Because this is a pilot, we have had to draw up protocols on who maintains responsibility for the patient under the care of the respiratory team. So patients referred to the team by a GP remain the clinical responsibility of the GP and the team keeps the surgery informed of any interventions and changes. Patients referred from within the hospital remain the clinical responsibility of their hospital consultant while a decision is made about discharge. However, once the patient is returned to the community they are under the care of their own GP, who is advised of the discharge and any subsequent developments.
Communication with GPs has been very important. The team policy is for same-day contact when changes are made to the care of a patient.
Feedback from GPs has been that they find it very helpful to have an update immediately. It also helps build up both the patient’s and the GP’s trust that the new system works, and they know they can use the service again next time there is an exacerbation.

Promoting the service

We had cards printed with the single access number. These have gone out to primary care along with information packs. We also remind GPs of the services at the end of any protected learning session we do.
And as respiratory teams come into contact with patients, they pass the cards to patients, so the patients are clear about accessing that service when they next need it.
Coming into the winter season, we also did a mailshot in October to all patients and anyone seen by the team within the past 12 months to encourage use of the phone line.

 

Unforeseen saving

The North West home oxygen contract is complex so we spent a lot of time looking at the use of oxygen.
We found that, unlike the case where a GP starts a patient on a drug and knows when that prescription has run out, there was no such system regarding oxygen. Patients were being supplied with oxygen and the CCG was being charged a daily rate in some cases, even though some of the patients were not actually using the oxygen any more.
The appointment of the oxygen co-ordinator has meant patients are assessed and reviewed systematically so their oxygen usage can be monitored effectively.
Combined with the changes from the new North West home oxygen contract, the CCG expects to make a saving in the region of £40,000 in the first year – a recurrent saving with no impact on patient care.

Outcomes

We had thought at the outset that primary care would be the highest referrer into this service but the heaviest users have turned out to be patients and carers. This self-management and ownership of their condition is very encouraging. About a quarter of the calls are just for phone advice and no actual contact is necessary. Often they are simply looking for confirmation that they have done the right thing.
More than half the calls to the triage single number service have come from priority one patients – the group most likely to require a hospital admission.
The role that has probably made the biggest difference for patients has been the band 7 nurse who is the triage co-ordinator. The team has struggled to find enough suitable patients for the band 6 occupational therapist and so the funding for this post will now go towards increasing specialist nurse capacity, which we are recruiting for now.
Since the service was introduced, emergency COPD admissions are reducing.  Between August and October 2012  Warrington admitted significantly below the England average and showed the lowest admission level in the North West. As every admission costs about £2,500,
we are confident that savings will be realised.
We underestimate how reluctant people are to go into hospital. For patients with COPD it can become a frequent and stressful part of their lives. If they are managed well in the community they don’t languish at home and they very much appreciate what’s being done.
Helen Pressage is senior commissioning manager and Dr Dan Bunstone is respiratory clinical lead for Warrington CCG

60-second summary

⦁ Initiative A two-year pilot integrating existing community and acute trust respiratory teams and introducing five new staff including a band 7 triage nurse and oxygen co-ordinator.
A single-access number allows patients and primary care to seek support for patients to stay in their own homes during a COPD exacerbation.
⦁ Funding £180,000 per annum
⦁ Outcomes Over half of calls have come from patients or carers from the group identified as the most likely to otherwise have become a hospital admission. Some £40,000 has been saved on oxygen provision though better monitoring of patients’ needs and use. Warrington has gone from having highest admissions to lowest in region.
⦁ Contact
Danbunstone@nhs.net



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