1. Right Care in the right place, human centred care at home and in the community Sally King MSc MCSP NMP Respiratory Specialist Physiotherapist

2. Gloucestershire Pop’n 620,000 Urban & rural demographic 1 CCG/85 Practices 1 acute provider/2 acute Hosptials 1 community provider 7 community hospitals Coterminous with local authority

3. National Drivers for Change Fiscal constraints & rising costs Unwarranted variation Quality of care issues (Mid Staffs, Winterbourne View) Ageing population, changing disease patterns and rise in LTCs Changing lifestyles with associated risks e.g. alcohol, smoking, lack of physical activity, poor diet Greater public expectations

4. External Review Trends Higher overall spend High non-elective spend (although some evidence of flattening) £5.7M non-elective spend on lobar pneumonia (unspecified) & pneumonia (unspecified) + £2.2M on unspecified acute-lower resp. infection vs. £1.8M on COPD Benchmark high on OP activity - 1 st OP attendances & new to follow- up ratio High spend on inahled therapy Benchmark high on average length of stay (Atlas of Variation)

5. Local context Acute-based Respiratory Assisted Discharge Team Community Respiratory Team: Pulmonary Rehab (300 pa) Telehealth (large-scale/1000 & specialist/200) Medicines optimisation Exacerbation management Home oxygen assessment service Medicine Use Reviews (community pharmacies) Admission and discharge bundle for COPD project

6. BUT…Not joined up Multiple hand-offs Replication Inefficiency/increased cost arising from: increased lengths of stay increased/unnecessary admissions increased OP/follow-up referrals & appointments increased primary care consultations inefficient deployment of staff ++ burden of care for (unwell) patients

7. Decision to integrate acute and community resp services Gloucestershire Respiratory Team: Will operate as a single, cohesive MDT (providing PR, assisted discharge, oxygen services, telehealth etc) Will have single organisation lead Will have clear clinical leadership & governance arrangements operate to agreed, clear/unambiguous eligibility & referral criteria Will have a single point of access Will be truly primary care facing/supporting (incl. training & education) Will have the freedom to innovate (e.g. COPD ‘hot clinics’, telehealth, phone advice etc) be fully integrated with: Hospital-based services Prevention services e.g. Stop Smoking End of Life care/services Integrated Community Teams Community pharmacies

8. The prize Improved quality of care for our patients More engaged and motivated workforce (appropriate use of skills) Potential to expand into other disease areas e.g. CAP/bronchiectasis Potential to use the model for other disease areas ?? CHD, diabetes etc

9. 9 Packages of Care Urgent Assessment Exacerbation Management Urgent review within 72 working hours Weekday 8:30-4:30 cover (currently) Urgent Assessment Exacerbation Management Urgent review within 72 working hours Weekday 8:30-4:30 cover (currently) Symptom management Respiratory medicines advice Non urgent response within 14 working days Symptom management Respiratory medicines advice Non urgent response within 14 working days Home Oxygen Assessment Service Community service CBG and pulse oximetry Respiratory Physicians supports Home Oxygen Assessment Service Community service CBG and pulse oximetry Respiratory Physicians supports Pulmonary Rehabilitation Countywide Service 7 week course 2x 2hour sessions/week Multi-disciplinary Team Pulmonary Rehabilitation Countywide Service 7 week course 2x 2hour sessions/week Multi-disciplinary Team Specialist Telehealth 90 units Patient selected by GRT Patient Case Managed Admission avoidance Reviewed every 3 months Specialist Telehealth 90 units Patient selected by GRT Patient Case Managed Admission avoidance Reviewed every 3 months Early Supported Discharge Reduces LoS <7 days Patients remain under Consultant care Supported for up to 14 days Early Supported Discharge Reduces LoS <7 days Patients remain under Consultant care Supported for up to 14 days Supported Discharge Complex respiratory needs Non resp. wards supported GRT support up to 3 months Discharged back to GP Supported Discharge Complex respiratory needs Non resp. wards supported GRT support up to 3 months Discharged back to GP Nurses led Outpatient Clinics OP Clinics in GHT and community setting Supporting Respiratory Physician clinics Nurses led Outpatient Clinics OP Clinics in GHT and community setting Supporting Respiratory Physician clinics Specialist respiratory advice Other respiratory diseases supported e.g. Asthma, Bronchiectasis Close links with Respiratory Physicians Specialist respiratory advice Other respiratory diseases supported e.g. Asthma, Bronchiectasis Close links with Respiratory Physicians

10. Telehealth 100 units Tool for identifying changes in the most respiratory vulnerable patients Criteria Frequent exacerbations Frequent users of service Geographically remote Live alone Step up/step down options between primary and secondary care Ability to use post discharge for short period

11. Specialist Team directly support RR Specialist Team support ICT Specialist Team advice and support Case Manage.

12. What next Continue to engage the wider team Develop case management workstreams using integrated care approach Work with academia to develop telehealth algorithms to reduce false alerts Adopt this approach in other disease areas i.e bronchiectasis, ventilation services, ILD Evaluate PREPARE model Develop Severe COPD clinics with representation from integrated team