1. 19 Ambulatory Care
Sensitive Conditions
COPD
November 2015

2. 19 Ambulatory Care Sensitive Conditions
Many patients present at A&E with problems which may have been avoidable if they had been managed better in the community. This is distressing for patients, but also wastes valuable A&E time and NHS money. Nineteen such 'Ambulatory Care Sensitive' conditions have been identified as ones where community care can avoid the need for hospitalisation.
19 Ambulatory care sensitive conditions
COPD
Pyelonephritis
Angina (without major procedure)
Iron-deficiency anaemia
ENT infections
Perforated/bleeding ulcer
Convulsions and epilepsy
Dental conditions
Congestive heart failure
Hypertension
Asthma
Gangrene
Flu and pneumonia (>2 months old)
Pelvic inflammatory disease
Dehydration and gastroenteritis
Vaccine-preventable conditions
Cellulitis (without major procedure)
Nutritional deficiencies.
Diabetes with complications

3. Unplanned Admissions for Chronic Ambulatory Care Sensitive Conditions : 2014-15
Locally we have some of the highest rates of admission for chronic ambulatory care sensitive conditions
NHS Indicators :

4. 19 Ambulatory Care Sensitive Admissions : Comparative Trends
The gap between our local position and the national position is not closing – we continue to have very high comparative admission rates.

6. the number of admissions
The 19 conditions have been classified into priority groupings based on :-
the potential financial opportunity (of moving to the 50th Percentile i.e. average)
the number of admissions
rank position of the CCG nationally (out of 211 CCGs)
A simple ‘Priority Criteria’ approach has been used to identify those areas with the greatest opportunity. These have been identified as follows.
2 x ‘Priority 1’ conditions can be identified using this approach:
COPD
ENT infections

7. Clear age profile linked to conditions
ENT : Mainly 0-4 ages
Asthma : <15’s account for 50% of activity
COPD : mainly patients aged 55 and over

8. COPD [BwD CCG + EL CCG Combined]
Mainly patients aged 55 and over
Average LOS over 5 days – including many patients with no primary procedure reported (80-90% of admissions have no primary procedure)
135 of the 697 patients (19.4%) have 2 or more admissions during the first 6 months of
85% of emergency admissions are coming via A&E
Clear seasonal pattern with increases in admission during the winter months

9. Emergency Admissions : Patients aged 65+ COPD
COPD in 65+ shows a winter seasonality with increased admissions in ‘Winter’…mainly via A&E
Respiratory admissions for 65+ spike significantly in winter

10. Insights from Central Lancashire
Emma Foster, Network Director for Adult Community Services, LCFT
Elizabeth Fleming, Head of Urgent Care, Pennine Lancashire CCGs

11. Contextext
Our journey so far as part of the Central Lancashire Health and Social Care – Whole System Transformation Programme...
Top 10 ACS Conditions analysis using NHS Better Care, Better Value Indicators
ACS conditions
 2013/14 LTH non-elective admissions
NHS better care, better value indicator at 25th percentile benchmark
Potential admissions opportunity
Reduction (%)
Potential financial opportunity (£)
Influenza and pneumonia
907
426
47%
1,365,757
COPD
1,080
528
49%
1,127,850
Dehydration and gastroenteritis
1,030
515
50%
765,488
Cellulitis
602
342
57%
568,696
Congestive heart failure
457
152
33%
423,149
Ear, Nose & Throat (ENT)
1,052
739
70%
403,972
Angina
603
421
328,356
Diabetes complications
294
122
42%
267,244
Asthma
474
307
65%
257,427
Convulsions and epilepsy
275
140
51%
152,525
Total
6,774
3,692
54%
5,660,466
19 Ambulatory Care Sensitive Conditions
WHY?
Prevalence
LoS
Number of admissions
Clinical opinion
National data
Prioritised 10 Local Ambulatory Care Sensitive Conditions
Jan’14 Apr’14 Apr’15
LoS (0-1) 279
LoS (2-7) 487
LoS (7+) 314
Total Admissions 1,080
Influenza, Pneumonia
COPD
Dehydration & Gastroenteritis
CHF
Cellulitis
ENT
Angina
Diabetes
Asthma
Convulsion & Epilepsy
Tranche 1
Tranche 2
Tranche 3
GUIDING PRINCIPLES FOR IMPLEMENTATION

13. Monthly Diabetic Medicine and Respiratory Medicine Outpatients - CSR/GP CCGs

14. COPD Intensive Home Support 7 day
Jul 14
Aug
Sept
Oct
Nov
Dec
Jan 15
Feb
Mar
Apr
May
June
July
Sep
BCBV QP
CQUIN
Mortality alert
COPD Consultant
Go live
Cardio-resp team
COPD Intensive Home Support 7 day
Ambulatory Care Pathway
NWAS CCPs
Quadramed marker
Rehabilitation Expansion
BTS Care Bundles
Pilot GSF MDTs
For 70 beds 8-8:
Part of 8a as service manager
2 x Band 7 WTE
4-5 x Band 6 WTE

18. 999 ED Patient GP UCC COPD Intensive Home Support
Primary care visiting scheme
COPD Intensive Home Support ED
Admit
Patient
COPD Intensive Home Support GP
Admit via MAU
COPD Intensive Home Support
UCC
Admit

19. 58% of referrals were for admission avoidance
15% of referrals from primary care (GPs and Practice Nurses) with two thirds of the primary care referrals from Chorley. The Chorley bias has also been the case previously
43% of referrals from community (patient self referrals, LCFT teams) with an even locality split
42% of referrals were from LTH with an even split between localities
29% of referrals were for supported discharge from hospital wards
13% of referrals were from ED or MAU to avoid ward admission

20. From July 14 to June 15 there were 1164 referrals for COPD HIS (avg
From July 14 to June 15 there were 1164 referrals for COPD HIS (avg. 97 p.m.)
Referral pattern shows expected seasonal variation
Referral split shows slight bias towards Chorley 645 (55%); Preston 519 (45%)

21. Data parameters
Primary diagnosis of COPD. Diagnosis codes used are taken from Everyone Counts Guidance which include:
J20 Acute bronchitis*
J41 Simple and mucopurulent chronic bronchitis
J42X Unspecified chronic bronchitis
J43 Emphysema
J44 Other chronic obstructive pulmonary disease
J47X Bronchiectasis
*J20 only with second diagnosis of J41, J42, J43, J44, J47
Admissions from all Lancashire CCGs into LTHTr

22. July June admissions with primary diagnosis of COPD and an average of 88 admissions per month July June admissions with primary diagnosis of COPD and an average of 81 admissions per month If December and January had been at ‘normal’ activity levels then there would have been 931 admissions between July 2014 and June 2015 Poor efficacy of flu vaccination is the likely cause for the rise in admissions over Dec and Jan

23. July 2013- June 2014 average LOS (primary diagnosis of COPD) 9
July June 2014 average LOS (primary diagnosis of COPD) 9.2 days July June 2015 average LOS (primary diagnosis of COPD) 7.2 days

24. July 2013- June 2014 average number of readmissions per month 17
July June 2014 average number of readmissions per month 17.1 July June 2015 average number of readmissions per month 15.7

25. What worked well? Key Clinical Leadership Senior Leadership
Collaboration and trust
Desire to work in an integrated way (specialist team)
Desire to work in a different way
Open referral pathway
Focused efforts and momentum
Invest to save

26. Further opportunities
Extended primary care network
High intensity users
How do specialist and generalist service integrate?
Cost-effective interventions
Spirometry
End of life care

27. NICE Clinical Guideline 101

28. Questions please?