PANNASH (Pulmonary Advancement Network for Newark and Sherwood Health)

Transcription

1 PANNASH (Pulmonary Advancement Network for Newark and Sherwood Health) Jan Balmer Programme Manager Long Term Conditions and Integrated Care Newark and Sherwood CCG

2 PANNASH A collaboration between Newark and Sherwood CCG, Sherwood Forest Hospitals Trust, County Health Partnerships, Patients, the Voluntary Sector and the pharmaceutical industry. Multi-disciplinary/ Multi-Partner Steering Group meet monthly Joint Working Agreements, Terms of Reference, Executive Sponsor Development work commenced May 2011

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4 Strategic Aims Improve the quality and effectiveness of care delivered to patients with COPD Reduce avoidable admissions to hospital Improve long term outcomes for patients with COPD in Newark and Sherwood.

5 Approach 3 key themes Improve quality of management in primary care Sustainability Increased support for patients to self manage Development of new community based services and pathways to reduce inappropriate use of acute services

6 Theme 1 IMPROVE QUALITY OF COPD MANAGEMENT IN PRIMARY CARE SUSTAINABILITY

7 3 Core Objectives Ensure all patients correctly diagnosed Ensure all patients being managed in line with NICE guidelines Increase skills and knowledge of HCPs

8 Systematic Gold Standard treatment reviews for all patients on COPD registers supported by PANNASH COPD Clinical Nurse Specialists. 3 PANNASH COPD Specialist Nurses working with 14 practices. ( Not WTE s) Funded by AZ but reporting to project manager Working to N and S COPD guidelines Systematic review of all patients 45 min appointment Delivered in conjunction with practice nurse where possible to facilitate up skilling and training. Spirometry to check diagnosis, disease severity, management, medication, inhaler technique, Pulmonary rehab, self management plan and education

9 Outputs to date 728 COPD patients have undergone Gold Standard Treatment Reviews ( as of Oct 12). By the end of the project we expect to have seen around 1000 patients 66 additional patients have been referred for Pulmonary Rehabilitation Of those pts seen, 458 have been recommended for treatment adjustment (around 10% resulting from misdiagnosis) Treatment changes initiated by GP Evaluation of patient experience via post clinic survey Majority of patients report that they feel more knowledgeable about their condition This what patients have said: First Class Service She explains it so that I understand

10 Systematic and structured education for primary care HCPs Confidence Mapping Exercise undertaken at start of project to identify priority areas for HCP training All practices completed Individual self assessment regarding competence / Skills in 5 key areas: Diagnosis, Patient management, treatment and assessment Inhaled & oral therapies Exacerbations PR, OT, Discharge review, palliative care and pt support groups

11 Systematic and structured education for primary care HCPs Highlighted general up skilling wanted but two key areas for action: Spirometry technique and Interpretation End of Life Care. An Introduction to End of Life Care for COPD two sessions delivered to 20 delegates in May and June by Dr Alpna Chauhan, Consultant in Palliative Care.

12 Training to deliver quality assured spirometry and accurate diagnosis New Vitalograph Pneumotrac Spirometers purchased and installed in most practices and training delivered. In-House one to one spirometry training delivered to practice teams by the PANNASH Nurse Support team in all practices. 3 Advanced Spirometry Interpretation group Workshops delivered by Dr Zahid Noor and Debbie Terry during June and July to 52 clinicians. Feedback from clinicians: Excellent case discussion, fantastic Practice, practice, practice time constraints don t allow as much mentoring time as I would like but this has really helped. Further practice based Group Spirometry accredited training sessions being provided until year end by an external provider (NHSI) and funded by Teva Uk.

13 Systematic and structured education for primary care HCPs Menu of varied training resources has been developed offering a range of both facilitated and online tools to accommodate individual training needs. Will now inform ongoing COPD training Confidence Mapping exercise to be repeated Jan 13.

14 Theme 2 INCREASED SUPPORT FOR PATIENTS TO SELF MANAGE

15 Patient Education and Self Care 560 patients have been given a Self Management Plan and education to support effective implementation these patients have also received an Action Plan to help with goal setting. Inhaler technique checked for all patients and education given where required Education on use of rescue meds and initiation where relevant A menu of additional patient support / education options has been developed to support practice teams discuss self care resources with patients. These include: Information Prescriptions Expert Patient Programme Health Peer Mentors Information on access to local support groups.

16 THEME 3 Development of new community based services and pathways to reduce inappropriate use of acute services

17 Communication between HCP s and Patients Development Workforce of Development, integrated Training and Educationcare Smoking Cessation, Health Promotion and Self Care pathways and services Level 1a PRIMARY CARE Public Health Population wide Prevention Disease awareness campaigns Social marketing Education Health promotion 1b GENERAL PRACTICE ACCURATE DIAGNOSIS Systematic Risk Profiling and disease severity stratification to identify risk and correct pathway Patients step up and down as risk profile changes Accurate performance and interpretation of post bronchodilator spirometry in general practice COPD Register Newark and Sherwood Integrated Model of Care for COPD Low RISK / Complexity Stratification of disease severity using NICE Clinical Guideline 2010 descriptors: Stage 1: Mild Stage 2: Moderate Stage 3: Severe Stage 4: Very Severe Referral to specialist support for diagnostic difficulty. Risk score recorded and reviewed annually Active Case Finding Disease prevention and Health promotion 2 GENERAL PRACTICE TREATMENT AND MANAGEMENT OF STABLE COPD Clinical management in line with NICE Clinical Guideline 2010 and NASH COPD Clinical Guideline 2011 Care Planning and individualised Care plans Support to Self Manage Education Programmes Annual Review Gold Standard Treatment reviews Anticipatory Care Flu Vaccination Offer Advance Care Planning 3 ENHANCED GENERAL PRACTICE COMPLEX / SEVERE DISEASE Intensive disease / case management by specialist teams as part of the MDT Telehealth / Telecare Community Specialist Services and clinics with MDT support Advance Care Planning Oxygen Assessment Planned Hospital Admission for those who need it and facilitated discharge via intermediate care to reduce LOS Co-ordinated Social Care Admissions Avoidance Schemes SPECIALIST COMMUNITY, HOSPITAL AND OOH SERVICES (Unscheduled Care) Admissions avoidance through Intermediate care and community navigator triage Advance Care Planning Hospital admission, proactive in reach and facilitated discharge where needed Follow up in community by COPD specialist nurses. HIGH RISK / Complexity Carer Support Special Patient Notes / 24/7 Access to specialist support PULMONARY REHABILLIATION FOR ALL PATIENTS MRC 2 and ABOVE 4 5 SPECIALIST COMMUNITY AND HOSPITAL SERVICES END OF LIFE / PALLIATIVE CARE MDT Team approach including social care Gold Standards Framework Prognostic Indicators Specialist Support Individual care plans

18 New Community COPD Team 3 x Specialist COPD nurses 1 per locality ( supported by dedicated HCA s) Plus Team leader Debbie Terry Physiotherapist and OT Consultant Respiratory Physician Dr Noor- ( 5 PA s per week) Case Management of complex COPD Exacerbation response and management O2 Assessment Pulmonary Rehab Community based clinics weekly ( in each locality) Alternate weeks nurse led clinic Aim is for majority of firsts and follow ups to be seen in these clinics Increased capacity of PR 2 additional venues ( 3 in total) Recruitment of staff underway Launch date TBC but likely Jan / Feb 13

19 Impact? 35 Newark & Sherwood COPD Admissions Year on Year / / / Financials (May 12) Year to date June 11 - May 12 15% Reduction Year to date reduction in admissions 19% 0 April May June July August September October November December January February March

20 Next steps.. Evaluation of primary care phase activity Implementation of community service COPD case finding / Smokers screening Asthma Telehealth Integrate COPD pathways within PRISM Integrated Care Programme

21 Learns Engagement from primary care vital Strong and visible clinical leadership Involve all stakeholders and affect all parts of the system Be systematic Education Education Education Communication Communication Communication It takes longer than you think Strategic project impact not immediate

22 Thank you