Trust launches a bio-psychosocial model based service to provide support to patients at risk of developing lung conditions, improving pulmonary rehabilitation and reducing patient waits

Synopsis

The lmpACT+ service is delivered by a team of Respiratory Consultants, Specialist Respiratory Nurses, Physiotherapists and Occupational Therapists along with admin and clinical support staff. The service has transformed specialist community respiratory services for people with Chronic Respiratory Disease living in Southern Derbyshire and Erewash.

The service re defines the patient pathway so that all patients are assessed using a Bio-Psychosocial model providing comprehensive holistic assessment and treatment plans. We are embedded in Primary Care and actively review all patients from the point of diagnosis through to the later stages of disease including advance planning.

Ambition

Respiratory RightCare Commissioning for Value data packs highlighted opportunities to reduce variation in non-elective admissions across Southern Derbyshire. Local stakeholder events highlighted key problems that needed addressing which included:

• Insufficient support was offered to patients at risk of a lung condition or following diagnosis.
• Opportunities to engage with patients at a time when behaviour change is more likely (a teachable moment) was not being harnessed.
• Insufficient collaboration between GPs, practice nurses and respiratory specialists.
• The level of skills and competencies across health professionals was variable which consequently led to patients receiving inconsistent messages about their condition.

The redesign of specialist respiratory services predominantly focused on developing a future model of respiratory care and the areas of greatest opportunity. Whilst reducing non-elective admissions was a clear outcome it was identified that there was greater opportunity of success by focusing on the very start of the patient pathway; prevention and diagnosis. This was to be achieved through delivery of

• Collaborative working with smoking cessation services to promote lung health awareness and support prevention of lung diseases.
• A case finding approach with Primary Care screening high prevalence areas such as substance misuse services.
• Specialist MDT assessments for all newly diagnosed patients including access to newly diagnosed education groups for asthma, COPD or bronchiectasis.
• Pulmonary Rehabilitation delivered from public gyms, which provides improved access for all patients.
• Consultant led virtual clinics delivered within practices to discuss complex cases, review diagnosis and review medication and provides the opportunity for peer learning.
• 7-day telephone helpline led by respiratory nurses, which is available for patients, GP practices, the ambulance service and other services requiring respiratory related support
• Community asset-based clinics led by respiratory specialists based on The Health Foundations ‘Making Waves’ model which targets hard to reach and vulnerable patients e.g. substance misuse patients.
• Specialist MDT assessment following admission to hospital to provide supportive discharge and follow-up within 2 weeks of admission.
• Fatigue and Breathlessness Groups for those with advance disease and heavy symptom burden.
• Home oxygen therapy and domiciliary non-invasive ventilation therapy support.

This model of care was developed through learning from evidence based practice. The NICE quality standards for COPD, Asthma and Pneumonia helped shape the new pathway through identifying what needed to Wrap around’ the recommended standards. Alongside this leaning from the following areas were utilised in development of the new services;

• Lambeth Virtual Clinics
• Portsmouth Mission COPD
• The Health Foundation MakingWaves/Rippie Project

Outcome

There is clear evidence as to the benefit of the service.

In the first 12 months the service was launched 4932 referrals were received.

The telephone helpline received 493 calls, directly avoiding 14 admissions. The majority of calls have been from patients (89%) with 9% from Primary Care. Callers have praised the accessibility of the helpline and 50% of callers have been successfully supported with clinical advice and 34% required a face to face assessment by the service, 11% were signposted to their GP and 5% being advised to go to accident and emergency.

207 patients were discussed in the virtual respiratory clinics, avoiding 83 referrals to secondary care (40%). Other outcomes from the virtual clinics included medication changes (23%), pulmonary rehabilitation referral (25%) and confirmation of new diagnosis (20%).

There have been 1122 patients referred for Pulmonary Rehabilitation with 279 starting a programme and a completion rate of 75% (209 patients). Patients have achieved fantastic outcomes with 93% demonstrating an increase in walking distance measured by the Incremental Shuttle Walk Test, 72-77% of patients have demonstrated an improvement in health related quality of life domains as measured by the chronic respiratory disease questionnaire (CRDQ).

Since introduction, non-elective admissions for all respiratory conditions have declined by 6% (7563 in 2017/18 to 7110 in 2018/19). COPD non-elective admissions fell 4% (1132 to 1086), asthma non-elective admissions dropped 16% (456 to 381). Emergency department attendances for asthma dropped 9 % (639 to 584) during this period.

Patient feedback collected from the community asset based clinic and the Fatigue and Breathlessness groups.

Results for 14 people surveyed who attended the asset based clinic;

100% enjoy attending the group and would recommend the group to other people.

100% report that it had been beneficial meeting other people with chronic respiratory disease and their health and wellbeing has improved as a result of attending the group.

Results for 36 people who attended the fatigue and breathlessness groups;

97% enjoyed attending the groups and 100% of all people surveyed found the group useful, with 80% reporting improved fatigue and breathing control.

88% of people report improved understanding of fatigue and oxygen therapy and 85% or people report improved health and wellbeing.

Testimonies from patients include;

“I haven’t been admitted to A+E since being able to control my breathing”.

“I have run a Breathe Easy group for 15 years; I thought I knew it all, but I don’t”

Spread

Service results and outcomes are disseminated through Quarterly newsletters sent to all Primary Care and to a Practice Nurse network, which is well attended. The public are updated via Social Media and specific feedback in the appropriate groups.

As a service we have been very active in submitting abstracts and posters with articles being published in as part of the Respiratory Futures updates. We have developed posters for FAB and which were presented at PCRS 2019, presented at the BTS Winter Meeting 2019 evidencing a reduction in non-elective admissions coinciding with the introduction of the lmpACT+ service. We have also presented at British Lung Foundation (BLF) events in 2019 to highlight the results of the lmpACT+ model and supporting the implementation of the service model to North Derbyshire.

Value

The service has been very successful in improving access to specialist services through bringing care closer to home. lmpACT+ is well established in Primary Care co-locating with CP’s to ensure we are accessible. We have also worked extensively to improve access to Pulmonary Rehabilitation through delivering the service in 7 different sites simultaneously across the county and continue to re-evaluate and adapt to areas of isolation resulting in record numbers of uptake.

The virtual MDT project has been particularly successful in improving value through reducing the number of secondary care referrals. Virtual MDT’s are held in Primary Care and attended by consultants, specialist nurse, practice nurse and GP. Patients are referred in to these MDT’s by practices who may require additional support or the service who believe treatment could be optimised by the practice. The vMDT’s have been successful in improving primary cares access to specialist support and patients have a shorter wait for specialist consultation.

In the first year (2018/19) 124 patients were discussed in the vMDT’s (32% to confirm diagnosis, 44% for symptom management and 25% frequently exacerbate). Outcomes of these discussions were 20% had a diagnosis confirmed on the day with 80% requiring further investigations. The majority (70%) of further investigations were managed in primary care and included peak flow diaries and repeated spirometry, 14% required FeNO and were managed by the service and 16% required secondary care referral for CT Chest or CPET.

Involvement

The service model was developed through multiple stakeholder engagement events attended by primary care, secondary care clinicians, ambulance services, psychological therapists, The British Lung Foundation, patient representatives, public health and commissioners. These stakeholder events were essential when identifying and understand the challenges of the health care system and scope out what wasn’t working well and why outcomes were not being achieved.

A core aspect of the service model that was developed following the stakeholder events was to engage patients to self-care more effectively. Each aspect of the service was designed to wrap around the patient and had resulted in a more comprehensive patient pathway straight from diagnosis through to advanced care that no other model supports.

The service is embedded in primary care co-locating with GP practices. This has been instrumental on both promoting the service and engaging with primary care to develop a more seamless and supportive patient pathway. Along with primary care we have case finding projects with smoking cessation services based in primary care to proactively identify those patients at risk of developing respiratory disease and engage them in the service pathway. In addition we work with third sector organisations to promote and deliver social prescribing projects such as singing groups and asset based groups to reduce social isolation and work actively with Western Power Distribution and the power up project to better support vulnerable people.