COUNTYWIDE COMMUNITY RESPIRATORY SERVICES. Pulmonary Rehabilitation Service Specification

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1 COUNTYWIDE COMMUNITY RESPIRATORY SERVICES Pulmonary Rehabilitation Service Specification Reference No: Version: 7 Ratified by: G_CS_36 Date ratified: 29 th July 2014 Name of originator/author: Name of responsible committee/individual: Date issued: July 2014 Lincolnshire Community Health Services Trust Board Elizabeth Hill, Clinical Specialist Physiotherapist (Respiratory Care) Quality Scrutiny Group Review date: Target audience: Distributed via: July 2015 (or prior if new Commissioning Specification launched) All staff Website 1

2 Lincolnshire Community Health Services Countywide Community Respiratory Services Pulmonary Rehabilitation Service Version Control Sheet Version Section/Para/ Appendix Version/Description of Amendments Date Author/Amended by 1 All July 2009 Elizabeth Hill 2 Reporting Mechanisms Addition Feb 2010 Julie Booker 3 Pge 4,5 Addition Feb 2010 Julie Booker 4 Page 3/para 2 Wording Elizabeth Hill Page 4 Wording Elizabeth Hill Page 6 Wording Elizabeth Hill All Formatting Elizabeth Hill 5 Page 4 Wording Julie Booker Page 6 Addition Julie Booker PR SOP Addition Julie Booker 6 All Formatting to current Trust standard 7 All Formatting to current Trust standard and new ref (old GuCPS030) Elizabeth Hill Elizabeth Hill 2

3 i. Version control sheet ii. NHSLA Monitoring Template Section Lincolnshire Community Health Services Countywide Community Respiratory Services Pulmonary Rehabilitation Service Contents 1 Aim of Service 5 2 Scope of Service 5 3 Referral Pathway 5 4 Inclusion Criteria 5 5 Exclusion Criteria 5 6 Communication Pathways / Access Timelines 6 7 Process of care 6 8 Outcomes of service / intervention 7 9 Reporting Mechanisms / Service Standards 8 10 Discharge criteria 8 Abbreviations 8 Page App. A Key Performance Indicators 9-11 App. B Standard Operating Procedure 12 Equality Analysis 3

4 NHSLA Monitoring Template This template should be used to demonstrate compliance with NHSLA requirements for the procedural document where applicable and/or how compliance with the document will be monitored. Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/group /committee Frequency of monitoring /audit Responsible individuals / group / committee (multidisciplinary) for review of results Responsible individuals / group / committee for development of action plan Responsible individuals / group / committee for monitoring of action plan Outcome of Service Annual audit of results LCHS CCRS Physiotherapists Annual Contracts Team / Matrons / CCGs CCRS Respiratory Physiotherapy Lead CCRS Respiratory Physiotherapy Lead 4

5 Countywide Community Respiratory Services Pulmonary Rehabilitation Service Specification 1. Aim of Service To provide sustainable Primary Care based Pulmonary Rehabilitation Programmes for COPD patients within the county of Lincolnshire. 2. Scope of Service All patients with COPD, who are functionally disabled by their breathlessness. The service will cover the geographic area of Lincolnshire Community Health Services, within the Practices and boundaries of Lincolnshire (Lincs East CCG, Lincs West CCG, South West Lincs CCG, South Lincs CCG). 3. Referral Pathway New referrals will only be accepted from the following health care professionals who must have seen the patient, explained the reason for referral, the proposed benefits of the programme, and gained their consent to refer using the appropriate referral document: Countywide Community Respiratory Team. Secondary Care Respiratory Team. Respiratory Physiotherapists. GPs, Nurse Practitioners and Practice Nurses. Case managers, Complex Case Managers and Allied Health Professionals. 4. Inclusion Criteria Patients with COPD who have functional disability due to their condition, despite receiving optimised pharmacotherapy as per local agreed guidelines and who fulfil the following criteria: Confirmed diagnosis of COPD i.e. confirmation by spirometric testing wherever possible. All patients who consider themselves functionally disabled by breathlessness and/or fatigue (usually MRC grade 3 and above (NICE Feb 2004 & 2010)). Motivated to attend and participate. Able to provide own transport to site of pulmonary rehabilitation or find suitable alternative transportation. 5. Exclusion Criteria Patients with the following criteria will be excluded from the service: Unstable angina. Acute LVF. Patients with no diagnosis of COPD. Uncontrolled hypertension. Uncontrolled cardiac arrhythmias. Myocardial infarction within the last 6 weeks. Immobility or any medical problem which severely restricts exercise or compliance with the programme. Putting you first is at the heart of everything we do 5 Chief Executive: Chairman: Andrew Dr Morgan Don White 5

6 6. Communication pathways/access Timelines Patient referred by standardised form or letter to Countywide Community Respiratory Services team, via post or fax. Referral within team acceptable using Systmone Tasks. Triage performed by Countywide Community Respiratory Services team clinician. Phone call made to patient where possible within 5 working days to inform them of referral, confirm interest, discuss programme and preferred venue of choice. This discussion is followed up with a letter regarding the phone call discussions and copied to the GP practice. For patients not accessible via phone, or for hard of hearing, letter sent within 10 working days to inform them of referral and inform of venue possibilities and copied to the GP practice. They will be invited to contact the team if they do not wish to receive the service, or if they would like to be considered for an alternative venue. Patients deemed not appropriate will be referred back to referrer, by person responsible for triage, indicating reasons for inappropriateness. Initial assessment offered and will take place within 18 weeks of referral. Offer is made by phone followed up with a letter, or solely a letter if the patient not available by phone / hard of hearing. Patient leaflet available (Referrer s information leaflet also available). Patients will then receive a place on the rehabilitation programme, starting within 2 weeks of assessment, ideally within their preferred location. Letter sent on patient completion of programme to GP, patient and referrer within 4 weeks (including results of programme). Patients declining two offers of an appointment for assessment will be referred back to referrer, except in exceptional circumstances decided by Respiratory Physiotherapist. Patients not attending assessment when offered, and without informing the team, will be discharged from the caseload (except in exceptional circumstances). 7. Process of Care Initial appointment should be offered within 18 weeks of receipt of referral. Consultation held within a NHS or non-nhs community setting. Consent to be obtained at the time of the appointment. Assessment to include full history taking, physical and cardiovascular examination, and physiological measurements taken. Physical assessment performed consisting of an Incremental and Endurance Shuttle Walk Test. The outcomes of the assessment to be discussed with the patient who, if findings are satisfactory, will then be offered a place on the programme. Self-reported questionnaires are completed prior to the assessment date to assess Quality of Life (Chronic Respiratory Disease Questionnaire) and Mood State (Hospital Anxiety and Depression Scale). A Personalised Management Plan is discussed with the patient at initial assessment or near the beginning of the course. This enables both patient and health professionals to establish goal setting. Each programme provided will be of 8 weeks with twice weekly classes. Carers, relatives or friends will receive invitation to attend with patients if desired. Written home exercise programme provided. Educational programme delivered with written supportive information. Re-assessment performed at the end of the programme akin to the initial assessment with a review of Goals set. Patients able to self-refer to Acute Respiratory Assessment Service (ARAS) via CCRS where available. 6

7 Patients meeting inclusion criteria for ongoing Respiratory Complex Case Management (Level 3), Respiratory Physiotherapy Services, Adult Oxygen Assessment Service to be offered appointments as appropriate (with patient consent) during or after Pulmonary Rehabilitation. Where appropriate, links will be made (with patient consent) with professionals within Lincolnshire Community Health Services, Secondary Care, Social Services, or the Leisure Industry and the voluntary sector with regards to patients immediate or ongoing care. Respiratory competency package available to support. Patients referred back to relevant primary care clinician, within Lincolnshire Community Health Services (e.g. CM, CCM, AHP, CCRS), and/or GP Practice on discharge 8. Outcome of service/intervention Proposed outcomes of the service will include: Improving patient health related quality of life. Increasing exercise capacity. Increasing exercise tolerance. Improved coping mechanisms. Improved self-management of exacerbations. Supporting admission avoidance. Supporting complex case management. Supporting palliative care. 7

8 9. Reporting Mechanisms/Service Standards Improved exercise tolerance as shown by an increase in Incremental and Endurance Shuttle Walk Tests. Improved QOL as measured by Chronic Respiratory Disease Questionnaire self reported. Improved anxiety and depression as measured by HAD score. Improved health care utilisation as indicated by a reduction in exacerbation rates and admissions to hospital. SystmOne Records. Throughput for the service, including numbers referred, assessed, completed, declined, etc. 10. Discharge Criteria Successful completion of Pulmonary Rehabilitation programme. Patient fails to attend/complete programme offered with no reasonable explanation given. Patient fails to complete programme and declines further attempts. Patient declines offered programme. Appendix A attached: Key Performance Indicators Appendix B attached: Standard Operating Procedure Abbreviations: COPD Chronic Obstructive Pulmonary Disease GP General Practitioner MRC Medical Research Council NICE National Institute for Clinical Excellence LVF Left Ventricular Failure CCRS Countywide Community Respiratory Services NHS National Health Service ULHT United Lincolnshire Health Trust ARAS Acute Respiratory Assessment Service QOL Quality of life CRQ Chronic Respiratory Questionnaire HAD Hospital Anxiety and Depression Scale 8

9 Appendix A COUNTYWIDE COMMUNITY PULMONARY REHABILITATION SERVICE KEY PERFORMANCE INDCATORS April 2010 INDICATOR MEASURE MECHANIC TARGET Self-care Improvement in patient s selfmanagement, patient s/carer s coping mechanisms and management of exacerbations (crisis management) supporting admission avoidance. Measure number of people who have been offered assistive technology 100% of patients will be aassessed for suitability of assistive technology (1/4 report) User/carer information All patients and their families will receive information and advice (including that which is relevant to their condition) appropriate to the rehabilitation phase and after care and service being delivered Letter confirming receipt and acceptant of referral will be sent to patient within 10 working days of receipt of referral 100% of patients will receive a letter confirming receipt of referral confirming acceptance onto the programme (Annual report) Patient information to be supplied by provider, at the most appropriate time in the rehab programme. Information to be available in appropriate format and taking into account patients level of understanding including the needs of non-english speaking patients) 100% of patients will receive a Welcome pack including a patient leaflet explaining the programme (Annual Report) 100% of patients and their families will receive specific information during the programme supporting the management of their condition (Annual Report) Record and report nationality and the number of ethnic minority patients seen within the service. The pulmonary rehabilitation service will develop information to meet the needs of the minority groups. (Annual Report) Service User Experience Provide regular feedback from users of the service to monitor achievement of the standards set out within this specification and to inform person centered planning To be measured by patient satisfaction surveys / questionnaire / CCRS audit. Service user surveys to be completed prior to discharge. 100% of patients to have service user experience survey offered prior to discharge. (1/4 Report) All patient feedback will be 9

10 Reducing Inequalities / Barriers The service must be: delivered at times convenient to patients, delivered in buildings that are accessible and have good access for people with disabilities To be measured by patient satisfaction surveys/questionnaire/ CCRS audit. Service user surveys to be completed on prior to discharge. Risk/Suitability Assessment to be undertaken of all venues. 100% of patients to have service user experience survey offered prior to discharge (1/4 Report) (see above information requirements regarding minority groups) Personalised Care Planning Patients and carers will be active partners in the decision making about their rehabilitation needs, be provided with appropriate information and personalised care plans. All patients will be offered personalised care plans. To include the following: Regular assessment and person centered goal setting and home plan. Choice about their care provision. Signposting and referral to other services medical and non-medical.) Secondary prevention. 100% of patients will be offered Personalised Care Plans (1/4 Report) 100% of patients will have record of health, well-being, and lifestyle needs, eg. BMI/Smoking cessation/anxiety and depression management). (Annual Report) Outcomes Clinical effectiveness and governance established to inform service change and achievement of programme goals and best practice. Evidence based outcomes tools - HAD/CRQ/St Georges/Incremental Shuttle walk test to demonstrate improved outcomes. 100% of patients have comparative outcomes scores at beginning and end of service. (6 Monthly Report) Performance and Productivity The number of patients offered access to Pulmonary Rehabilitation will increase from the baseline of 2% to 5%. Record and report the number of patients: Starting programme Completing programme DNA Leave programme early (record timescale and reason) 640 places will be offered to patients to attend Pulmonary Rehabilitation annually. (1/4 Report) 75% of all patients commencing Pulmonary Rehabilitation will complete the programme through to final assessment Access People with COPD will have access to a community run Pulmonary Rehabilitation programme, to include: Record and report on the following: Time from referral to pre assessment 100% of patients referred to the service will be seen within four weeks of pre assessment, and will wait 10

11 pre-programme appointment, assessing their health status and exercise capacity within 18 weeks of date of receipt of referral. Rehab programme must commence no longer than 4 weeks post initial assessment Time from pre assessment to commencement of programme No longer than 18 weeks from point of referral (1/4 Report) Workforce review and development Reduce inappropriate referrals into service. One member of staff for every eight patients must be in attendance at each session Workforce and structures will be in place to ensure a quality service is delivered and continuous service improvement takes place Number of posts filled / numbers of vacant posts. Number of staff who have annual appraisal. Numbers attending relevant training Number of staff demonstrating achievement of competencies. Clinicians will participate in clinical audit and reviews, retaining evidence of their undertaking such as reports and action plans Record and report on a quarterly basis the origins of referrals to the service. Review HR records / audit of training plan on annual appraisal. Inappropriate referrals to the Pulmonary Rehabilitation service are reduced by 50% in Year 1 increasing service capacity (1/4 Report) 100% staff working within the service will have an annual personal development review (Annual Report) 100% of staff will be trained and have the appropriate competencies to deliver the services outlined. (Annual Report) 11

12 COUNTYWIDE COMMUNITY RESPIRATORY SERVICES PULMONARY REHABILITATION STANDARD OPERATING PROCEDURE Referralinto service: - via post, or fax - usingreferralformor letter (teamtemplate) - viatask internally for referralwithin team - accordingto specifiedcriteria (see appendix) Triage - by qualifiedmember of CCRS Team - w ithin 5 w orking days of receipt - in accordance with inclusion/exclusion criteria Abbreviations: S1 - Systm One Application UTA - Unable to Attend DNA - Did not attend PR - Pulmonary Rehabilitation HCP - Health Care Professional CCRS - Countywide Community Respiratory Services Referral No - Register on S1 as not accepted - scanin referral - file paperw orkindischarged - sendnon-acceptance letter to referrer and patient w ithin 10 w orking days of referral Yes - Register on S1 as accepted on put onto w aitinglist - scanin referral - make up paper file (first time) andfile in cabinet Can the patient be phoned End of episode NO - - No telephone - Deaf YES - - Phone call to patient w ithin 5 w orking days to confirm referral, desire toattendprogramme and preferred choice of venue - sendpatient letter confirming discussionw ith copy to GP w ithin 10 w orking days of referral - Send w aitinglist letter to patient w ith copy to GP, confirming referral, selected venue and options available w ithin 10 w orking days of referral Can the patient be phoned - Add patient back onto PR w aiting list in order of date of referral NO - - No telephone - Deaf YES - Initial appointment offer: - Appointment to be w ithin18w eeks of referral (receipt) - Phone call 4-6 w ks beforelocalprogramme to book place Patient accepts Patient does not accept - updatenotes for UTA - senduta letter/taskto referrer/gp/hcp - in extenuating circumstances clinician decides reason(s) acceptablefor UTA and to - Send out initial appointment letter complete w ith starter pack4 w eeks prior toappointment - document action in patient records Patient declines completely/rip Patient unable to attend Offered 2 classes and UTA - Attends initial PR assessment Initial PR appointment attended DISCHARGE - Update notes, scan onto S1 - letter to referrer +/or GP to inform - d/c fromcaseload - signpost to relevant HCP (e.g.cm/ccm/ahp/ccrs) - shredany paperworkinaccordancewith Information Governance Policy - refer backto the GP for review if there arehealth reasons for theuta - Completes rehab programme in full - Clinician decides drop outw ith acceptable reason - continue rehabat later date - document in notes - refer onto GP/HCP if needed - DNA appt w ith no reason given - Drops out w ith no reason/rip End of episode - documentin notes - scan in documents - shred any paper documents oncescannedin accordance with Information Governancepolicy - results sentto GP, patient, (consultant) (within one month of completion) - refer on to HCP as required particularly if any pressure relieving equipment ordered - offer phonereview / home visitas required w ith patient for nomore than3 months post programme Phone review not required Phone Review / home visit required: - discuss health status, exercise levels and any concerns - review mandatory assessments whereindicated - refer on to HCP as required 12

13 Equality Analysis Introduction The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and those who do not. Foster good relations between people who share a protected characteristic and those who do not. The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality, but doing so is an important part of complying with the general equality duty. It is up to each organisation to choose the most effective approach for them. This standard template is designed to help LCHS staff members to comply with the general duty. Please complete the template by following the instructions in each box. Should you have any queries or suggestions on this template, please contact Qurban Hussain Equality and Human Rights Lead. 13

14 Name of Policy/Procedure/Function* LCHS Countywide Community Respiratory Service Pulmonary Rehabilitation Service Specification Equality Analysis Carried out by: Liz Hill Date: Equality & Human rights Lead: Qurban Hussain Date: Director\General Manager: Andrea Blakeley Date: *In this template the term policy\service is used as shorthand for what needs to be analysed. Policy\Service needs to be understood broadly to embrace the full range of policies, practices, activities and decisions: essentially everything we do, whether it is formally written down or whether it is informal custom and practice. This includes existing policies and any new policies under development. 14

15 Section 1 to be completed for all policies A. B. C. D. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are expected to be Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details Will/Does the implementation of the policy\service result in different impacts for protected characteristics? The Service Specification is intended to outline the processes carried out in the delivery of the Countywide Pulmonary Rehabilitation Service. The intended beneficiaries are the staff within the team and any health professional that wishes to refer into the service. It has an impact on patients in the fact that it outlines the processes they are involved in either before or during the service. Inequalities have existed within the service regarding wait times but these are being resolved through flexible cross county working Not known Disability Sexual Orientation Sex Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers Yes If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 No The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: Elizabeth Hill Date:

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