Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick
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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick NHS London Respiratory Team Lead Consultant Respiratory Physician, Whittington Health & NHS Islington Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick
- 1. How to manage… exacerbations of COPD, asthma &… in hospital Delivering high value integrated care with KREDIT? Dr Louise Restrick, NHS London Respiratory Team Lead Consultant Respiratory Physician, Whittington Health & NHS Islington Improving Outcomes Right Care Doing the right things and doing things right Right diagnosis including severity Addressing respiratory failure and breathlessness Structured admission & care planning conferences? Value framework KREDIT 1
- 2. Aligning and sharing agendas… Patients present with breathlessness… Frightening … and disabling Clinicians focus on respiratory failure Frightening !!! Breathlessness and hypoxaemia Present to ED pathways of care Respiratory failure Care at home? treatment in hospital Breathless and low oxygen saturation Breathless Hypoxaemia with normal = oxygen Low oxygen saturation saturation Low oxygen saturation but not breathless Breathlessness 2
- 3. Right Care for Respiratory Failure Getting the diagnosis right Exacerbation is not the same as pneumonia … Assessing severity and prognosis … Getting oxygen therapy right High flow O2 increases mortality - from 7% to 11%* Using Non-Invasive Ventilation appropriately 11% given NIV had metabolic acidosis…* * Roberts et al NCROP Thorax 2011:66;43-48 Right Care for Respiratory Failure …NOT EASY Need clinicians with respiratory diagnostic & treatment knowledge, skills & expertise Appropriate NIV halves mortality due to respiratory failure in acute exacerbations of COPD from 20% to 10% Getting it right saves lives 3
- 4. Value Framework Health Value Cost = Outcomes Health Outcomes Patient defined Cost of delivering bundle of care Outcomes NB Outcomes as defined by patients & their families So we have to ask & listen … Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483 What patients & families tell us… ‘I don’t want to die’ ‘breathlessness is frightening and disabling’ 4
- 5. Right Care for disabling breathlessness…NOT EASY To deliver evidence-based support for patients to stop smoking as treatment for sick smokers Need long term condition clinicians with behaviour change & motivational interviewing skills To enable patients to benefit from pulmonary rehabilitation KREDIT* Respiratory Teams’ Shared Values … Kindness Respect Empathy Dignity Interest TRUST *Whittington Health, London Respiratory Team and … 5
- 6. COPD ‘Value’ Pyramid What we know…. Cost/QALY Support to stop smoking Triple Therapy is key TREATMENT for £35,000- £187,000/QALY sick smokers … LABA Where are the sick £8,000/QALY smokers? Tiotropium £7,000/QALY … in our hospital beds Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £1,000/QALY in “at risk” population Is current smoking an issue in COPD? 2010 ERS Audit 6
- 7. Effect of smoking on hospital admissions for COPD and asthma ….and??? For every 1% increase in prevalence of smoking in your COPD population there is a 1% increase in COPD admission rates For every 1% increase in prevalence of smoking in your asthma population there is a 1% increase in asthma admission rates Emergency respiratory admissions: influence of practice, population and hospital factors Purdey S et al J Health Services Research Policy 2011;16:133-40 Changing how we think about smoking ‘Smoking kills, stopping works’ Sir Richard Peto 2012 Tobacco dependence Sick smokers are admitted to hospitals - acute and psychiatric Evidence based quit smoking treatment is the most important treatment for sick smokers: Behaviour change support and quit smoking medication Delivering value in tobacco dependence Top 10 Questions … 7
- 8. Does your hospital have a BTS Quit Smoking Champion lead? Do your consultants believe that Quit Smoking treatment is high value for their patients? Does your hospital provide NRT routinely on admission for smokers? Are your hospital staff able, & confident to, prescribe Quit Smoking medication? 8
- 9. Do you have a Quit Smoking service for patients and staff in the hospital? Services Offered: • Outpatient Quit Smoking Clinics: for patients and staff • Inpatient Assessment for Quit Smoking Support • Special Clinics – Pre-operative Assessment & Maternity Support for smokers to quit Do your hospital staff know your Quit Smoking advisors and refer to them? Do your hospital staff routinely offer ‘Very Brief Advice’ to every smoker? Online training module WWW.NCSCT.CO.UK/VBA ‘This training is relevant to anyone who comes into contact with smokers… GPs, practice nurses, hospital doctors, pharmacists & other healthcare professionals. … certificate on successful completion to provide evidence of continuing professional development (CPD).’ Do your hospital staff have and use behaviour change skills to support smokers to stop? 9
- 10. Do your hospital decision makers believe that Quit Smoking treatment is high value for patients and staff? Do your commissioners believe that Quit Smoking treatment is high value for patients and staff? Increasing the value of care in COPD COPD Discharge Bundle Hopkinson et al ThoraxCLARHC Developed by 2012:67:90-92 Pre Bundle % With Bundle % 18 100 14 68 55 98 59 91 41 39 10
- 11. Developed by CLARHC Hopkinson et al Thorax 2012:67:90-92 CQINS to incentivise high value care 2011 11
- 12. One story from a respiratory ward 50+ year old man Schizophrenia since 20s Tobacco addiction: 60 pack-years Cannabis addiction:100 joint-years Severe COPD Lives alone, isolated, not working 13 admissions and 112 bed-days in 2 years Further emergency admission: ‘Unable to breathe’ & severe (acute on chronic type II) respiratory failure … Due to exacerbation/worsening of severe COPD & smoking tobacco and cannabis ie sick smoker Treated on respiratory ward including non-invasive ventilation & quit smoking interventions … 50+ year old man What he told us mattered to him Disabled by breathlessness Scared to use lift to his xth floor flat Too breathless to go up stairs indoors Sleeping on piece of foam under stairs Electricity had been turned off 12
- 13. Care Planning Conference why and who High risk of premature death Current care model not working Under-treated schizophrenia preventing respiratory treatment Untreated tobacco and cannabis addiction Unsafe home situation Bed-days +++ Respiratory team: physician, ward sister, nurse specialist, physiotherapist, occupational therapist, quit smoking advisor Mental health team: care co-ordinator, dual diagnosis specialist, psychiatrist invited but unable to attend Housing officer Patient Londoners dying from smoking ‘1 in 5 deaths due to smoking’ 13
- 14. Care Planning Conference: what Person-centred integrated care Identified care and treatment gaps and needs Named actions and responsibilities No social worker... Smoking as tobacco addiction NOT a life-style choice Anti-psychotics safe – regular depot injection given Community respiratory support at home Common needs assessment by mental health team Rehoused to supported ground level accommodation Integrated care: care planning conference Outcomes for 50+ year old man • Alive • Ground floor warden controlled flat • Mental health good, goes out regularly • Still smoking but much less • Supported at home by GP, warden, mental health team and community respiratory team as needed • Mostly telephone follow-up • No admissions in 2012 or since … 14
- 15. Person-centred integrated care in hospital Care planning in out-patients too Respiratory Nurse Specialist Respiratory Physician Mental Health Quit Key Smoking Worker Advisor Delivering high value care for exacerbations of …LONG-TERM conditions in hospital • Workforce with the right competencies and interests – Respiratory knowledge, skills and expertise – Long-term conditions interest and expertise – Behaviour change and motivational interviewing skills • Design pathways around exacerbations of LTCs not episodes – Acute medical assessment unit model does not work for these patients! • Structure to admission – green days not red days – Safe respiratory failure care – Quit smoking support & medication as treatment for all sick smokers – COPD discharge bundle interventions – Diagnose & optimise care of all underlying long-term conditions • Levers – CQINS, measure value outcomes – Mortality & days at home in year or bed-days/year 15
- 16. A respiratory provider manifesto I am a long term conditions clinician I care about value I know how to assess and support patients and drive improvements I work in a team I personally deliver high value care 16