1. “COPD specialist nurse in the Community” Tony De Soyza, AHSN-NENC Regional Respiratory Clinical Lead Snr Lecturer Newcastle University Honorary Consultant Respiratory Medicine Freeman Hospital

2. Why COPD in the community? –Majority of patients are in primary care –Significant local experience that there was –Misdiagnosis is a local (and international) problem- up to 20% –Guideline compliance variable (pharmacotherapy) –Variation in care –Self management plans –Pulm Rehab referral

3. 2 Parallel Projects Newcastle West (Sue Hart) –Audits of care –Self management plan –Prepare for “research in real life trial” Newcastle North and East “plus one”… –Audits of care –Self management plan –Nurse support network

4. Unifying aims Support primary care (education and hands on) Support patients Develop overview of what is working and what isn't Map where “joint working”/ leverage funding might bring about change

5. The Project Proposal To identify all patients discharged from hospital in the previous 12 months following exacerbation and to facilitate expert review of their condition in their own GP practice or in their place of residence for housebound patients. A second (later) target group will be those patients at risk of admission i.e. > 3 exacerbations in 12 months and / or FEV 1 <40% predicted.

6. Service Structure Reviews will follow a standardised Annual Review template but will focus heavily on patient education. Mentorship support in the development of consultation skills offered to Practice Nurses. Where patients are already under the care of a Community Matron or District Nurse, joint review will be suggested. Ensure optimal pharmacological management, including immunisations, according to guidelines. Ensure an exit strategy is in place; work to implement practice plan to ensure future reviews of all patients post exacerbation and post hospital discharge.

7. Sign Posting Where Appropriate Smoking cessation advice for all current smokers with onward referral to smoking cessation services as appropriate. Where inhaler technique training has not been possible – referral to Community Pharmacist for review (MUR). Where MRC Dyspnoea score is >= 3 – offer referral to Pulmonary Rehabilitation. Where MRC Dyspnoea score is >= 4 – arrange medical review Where there is evidence of anxiety (HAD >11)– offer referral for CBT.

8. Background: Research In 2014 the management in primary care of 3075 COPD patients in Newcastle was audited and compared to NICE Guideline standards. Key findings include: –63% had no record of exacerbation frequency –79% had no quality of life measurement –53% had no inhaler technique assessment –86% had no self management plan or emergency rescue pack

9. Strategy Practice manager meetings “early dissemination” Audit via RAIDR* Nurse with COPD skills come to practice with dedicated QoF compliant COPD review slots (Practice to arrange patients coming in) > 15 clinics set up in 9 Practices Housebound patient visits

10. Outcomes Specific Progress: –6 month lag to appoint nurse, –Engaged with 9 practices (visited more but others didn’t show uptake) –159 patients reviewed = 52% target 18.5% DNA rate Barriers to COPD reviews: –Unreliable primary care data in data systems (RAIDR) – has led to inappropriate targeting in all practices. –RAIDR has been incorrectly identifying high-risk patients based on issue of inhaled medication; therefore data bears no relation to clinical definitions of high risk patient. –Issues in some practices – significant number of clinic cancellations by practice staff who appear not to have prioritised setting up clinics for COPD review

11. Practices 1.St Anthonys= 12pts (ave per session 6) 2.Holmside =22pts (6) 3.Saville=19pts (6) 4.Prospect =3pts (1.5) 5.Cruddas Park =16pt 6.Walker =24pts (4.8) 7.Denton Park= 7pts (3.5) 8.Falcon =23 pts (6) 9.Thornfield = 10pts (5)

12. Of the reviews…. 159 patients reached Large variations in OPD vs housebound/ practice Overall

13. Exemplar(s) 19/03/201502/06/2015 NOP reviewed46 Inh tech trained44 inh device change11 SMP new31 SMP update1 rescue meds1 already got3 new px1 ref smoking ref pulm rehab2 PR declined12 ref CBT1 ref talking therapies MUR44 change in meds flu/pneum21 ref medical11 in surgery3 housebound16 total reviews 410 dna2 no previous review6 06/02/201510/02/201520/02/201527/03/2015 NOP reviewed6655 Inh tech trained6255 inh device change11 SMP new2244 SMP update11 rescue meds21 already got23 new px ref smoking ref pulm rehab PR declined423 ref CBT ref LTOT1 ref talking therapies1 MUR6655 change in meds1121 flu/pneum21 ref medical111 in surgery housebound6655 total reviews 6121722 dna11

14. Practice nurse training –This was put in place in as many practices as we could engage! Superceded by formal AHSN COPD training program and training

15. Learning points Highly skilled nurses are hard to find (and retain!) Primary care is swamped –(as if you didn’t know this) Specialist nurse can access and make good reviews of hard to reach patients –Timescale insufficient to show admission reduction –Can show alignment to NICE 2010 COPD guidelines Priorities are cyclical whereas COPD as a healthcare burden isn’t

16. Discussion points Solutions may need Behavioural and Organisational change –not simply to provide “free” resource? Radical approaches are likely needed to up our game in COPD as “iterative changes” unlikely to be adopted at scale and pace..

17. Summary We know we have a problem with COPD Practices are struggling to manage this even with support Joint working project have been offered but are we ready to engage with them?

18. THANK YOU ANY QUESTIONS ???