Key recommendations
- Review of respiratory patients by a 7 day multidisciplinary integrated respiratory team (IRT) promotes accurate diagnosis and acute management, and helps to prioritise inpatients for a respiratory bed.
- Working with community rapid response and hospital at home services enables admission avoidance and early supported discharge where this is appropriate.
- All clinicians looking after patients with long-term conditions need training in collaborative care planning, including those in an acute setting. Care plans should be co- created with patients and shared with their primary care team.
- Respiratory ‘virtual clinics’ allow joint working between primary care and specialist teams to systematically review the diagnosis and long-term management of respiratory patients
- Engagement, support and long-term commitment by local clinical commissioning groups (CCGs) are critical enablers for integrated teams
- A well-defined team purp
ose, strong leadership, robust communication, clear competencies and a supportive approach allow the patient and staff benefits of integrated working to be realised over time.
Our story
The challenge
Our aim is to improve the respiratory health of an inner London population with high deprivation and smoking rates, and high premature mortality due to respiratory disease.Local context
Our local population consists of around 600,000 people, served by two clinical commissioning groups (Lambeth and Southwark CCGs). King’s Health Partners (KHP) includes two large teaching hospitals and a mental health trust providing acute and community services within an Academic Health Sciences Centre.Our solution
The multidisciplinary integrated respiratory team (IRT) at KHP has a vision of ‘teams without walls’. We aim to bring specialist care closer to the patient. The purpose of the service is to ensure that patients living with a long-term lung condition, and their carers, experience high value, collaborative and coordinated care wherever they need it. Our guiding principles are right care and value based healthcare.We work in an integrated way across two acute hospitals and the community delivering chronic obstructive pulmonary disease (COPD), oxygen, pulmonary rehabilitation and supported discharge services. Key components include the IRT working in acute trusts supporting accurate diagnosis and acute management, communication and post discharge care, virtual clinics (VCs) in the community, a single point of referral to IRT from the community and optimising respiratory prescribing.
Engagement, support and long-term commitment by the local CCGs have been critical enablers for the development of the IRT. A well-defined team purpose, strong leadership, robust communication, clear competencies and a supportive approach allow the patient and staff benefits of integrated working to be realised over time. Promoting professional development, sharing success and reflecting on difficult experiences have helped the IRT to keep a sense of purpose and momentum.
Outcomes
There has been a marked reduction in acute COPD admissions to Kings College Hospital (within appropriate HRG groups) from 296 in 2012-13 to 196 in 2014-15 (a 34% decrease). Total COPD admissions have also decreased by 8%. Length of stay for COPD admissions (within appropriate HRG groups) has reduced from 4.45 to 3.7 days (a 17% decrease).The focus in our respiratory virtual clinics (VCs) is to promote evidence-based high value care and to reduce spend on inappropriate inhaled medications, which can then be reinvested elsewhere in the pathway. Both Lambeth and Southwark have seen reductions in the proportion of therapy prescribed as high dose steroid inhalers in the time the VCs have been running. It is estimated that this has saved £200,000 in 12 months in just one CCG. A proportion of this has been reinvested in the high value treatments which have seen more demand from primary care as a result of awareness raising through the VCs, eg community pulmonary rehabilitation.
Staffing
The IRT consists of specialist respiratory nurses, physiotherapists, a respiratory pharmacist and a smoking cessation advisor, working seven days a week across two acute hospital sites. There are seven staff members on each acute site, of whom a minimum of two are based in the community on a rotational basis. The team is led by an integrated respiratory consultant (Dr Irem Patel) and two locality GP respiratory leads (Dr Noel Baxter and Dr Azhar Saleem).Methods
A number of initiatives have allowed us to improve care for respiratory patients across KHP:- Seven day working of the team aims to ensure that every bed-day counts for patients admitted to hospital with exacerbations of airways disease.
- Close links with the emergency department, smoking cessation services, hospital and community pharmacy, clinical psychology, community mental health, dietetics and palliative care to ensure coordinated care.
- Aiming for every patient to have a person-centred specialist review, focused on collaborative care planning, and for patients to have a supported discharge including the use of the COPD Discharge Care Bundle.
- Working with community rapid response and hospital at home services on admission avoidance and early supported discharge where appropriate.
- Follow up of patients by telephone and at home post discharge, working with other agencies to coordinate onward care, as patients are often elderly, breathless and have complex co-morbidities or social issues.
- A seven-day telephone advice line for patients and local GPs.
- A single point of referral in the community, which means that referral to any of the IRT services from primary care comes first to one of the two locality GP leads, enabling peer-to-peer support and ensuring patients receive the right care in the right place first time.
- Respiratory virtual clinics which run twice a week in primary care. The focus of VCs is joint working between primary care teams and the IRT to systematically review the diagnosis and long-term management of the respiratory patient caseload. VCs have resulted in major shifts in the focus of COPD care in Lambeth and Southwark, supporting responsible respiratory prescribing and reducing harm and waste through inappropriate use of inhaled therapies.
What next?
Communication barriers are a constant challenge, with IT systems that are not fully joined up across the health and social care sectors. Electronic patient records help to allow multiple sites to share information about patients and this is an evolving process.Patient feedback
Inspired by the care they received, one of our patients wrote a poem to express their feelings about their experience.‘You do things,
Then disappear,
You’re so unassuming
It’s as if you were never here.
But you were,
You are,
You’re everywhere.
You are the ones
Who really care.’
- Written by a King’s patient in 2015 who has been supported by the Integrated Respiratory Team.
Who’s involved?
Irem Patel is an integrated respiratory physician working in South East London, and is COPD, Asthma, Oxygen and Smoke Free lead for Kings College Hospital NHS Trust. Towards the end of her postgraduate training she became increasingly interested in healthcare delivery for long term respiratory disease and bringing specialist care closer to the patient.
This case study was first featured on the Royal College of Physicians’ Future Hospital Tell us your story web pages, where you can read a full range of case studies.
The Royal College of Physicians’ Future Hospital Programme aims to promote new models of delivering medical care in hospital and community settings. The programme is seeking to collect and share examples of teams and individuals who are delivering care in innovative ways to improve patient care. You can read all the case studies at: https://www.rcplondon.ac.uk/projects/future-hospital-tell-us-your-story