1. Integrating primary and community care services for improved management of COPD in the community
Andrew
Introduce the team:
Andrew Heap
Senior Manager Primary Care Engagement
Murrumbidgee Primary Health Network
Summa Stephens
Community Care Manager
Murrumbidgee Local Health District
Sue Wealands
Nurse Unit Manager
Community Care Intake Service
Melanie Reeves
Portfolio Manager
Murrumbidgee Primary Health N
Narelle Mills
Senior Manager Commissioning and Procurement
etwork
Thursday 29 March 2018

2. 1. Rationale for change…
Asthma/COPD nurses working in general practice not well integrated with other services.
Inequity in access to pulmonary rehab and ongoing maintenance programs in the community.
A lack of opportunity and resources to encourage patients to better self-manage their COPD
High rates of possible preventable hospitalisations of people with COPD
Respiratory hospitalisations account for 6.2% of total hospitalisation (highest in NSW PHNs)
20% of all respiratory hospitalisations were due to COPD – 78% of these aged 65 years and over (1.7 times the NSW COPD rate)
Andrew
The Key Issue that the Integrated Care Program is seeking to address (i.e. the problem statement) (For Who and Why?)
The Murrumbidgee region experiences high rates of possible preventable hospitalisations of people with COPD and currently there is inequity around access to pulmonary rehab and ongoing maintenance programs in the community. Whilst there are a small number of asthma/COPD nurses working in general practice to support they are not well integrated with other services. Significant resources have been allocated to upskilling practice nurses and GPs, however general practice data continues to show poor spirometry rates across the region, leading to delayed diagnosis and poor care planning
Target population: People who live in the Murrumbidgee who are willing to self-manage their COPD.
In , respiratory hospitalisations in MPHN accounted for 6.2% of the total hospitalisations (7472/120512). This equates to a rate of per 100,000 (NSW per 100,000). Of all the PHNs in NSW, MPHN had the highest rate of respiratory hospitalisations.
In one fifth of all respiratory hospitalisations in MPHN were due to COPD (1476/7472). Of the 1476 COPD hospitalisations, 1155 (78%) of the persons hospitalised were aged 65 years and over. MPHN has the highest COPD hospitalisation rate amongst all of the PHNs in NSW for those aged 65years+, which equates to 1.7 times the NSW COPD hospitalisation rate (MPHN per 100,000; NSW per 100,000). As for COPD deaths, there was an average of per annum in MPHN between 2014 and MPHN had the 2nd highest rate of COPD deaths amongst all PHNs in NSW (MPHN 32.2 per 100,000; NSW 24.3 per 100,000). Trend data shows the rate of COPD hospitalisations and deaths in MPHN have remained stable over the past ten years.

3. 2. Aims and objectives….
100% of newly diagnosed patients with COPD in general practice will be linked with self management strategies within 12 months of diagnosis
Map current COPD/respiratory care services, including pulmonary rehab and early intervention programs
Identify current roles and linkages between General Practice, COPD/respiratory care services (community and primary care) and Allied Health
Identify gaps and areas for improvement
Develop partnerships between primary care and community based COPD services
Improve access to self-management strategies
 Narelle
100% of patients diagnosed with COPD will be linked with self management strategies within 12 months of diagnosis
Self management strategies defined as:
Pulmonary rehab – medication management, exercise, diet, disease information, social support through group activity
QUIT smoking support
Identificaiton of social determinants
Care plan and sick day action plans.
Mel
The Core Aims and Objectives of the Integrated Care Project / Program (What?)
Map current COPD/respiratory care services, including pulmonary rehab and early intervention programs
Identify current roles and linkages between COPD/respiratory care services (community and primary care)
Identify gaps and areas for improvement
Develop linkages between primary care and community based COPD services
Improve referral of patients to rehab programs including early intervention programs
Ensure equitable access to pulmonary rehab services

4. 3. Diagnostics Project INTEGRATE Dimension Room for improvement
Person-centred care
Carer support; Patient access to health information; sharing information between services
MDT assessment and care planning; fractured care transition; Community involvement
Shared accountability; Collaborative agreements; inter and multi disciplinary teamwork
Clinical integration
Professional integration
5 whys
Why- Patient not confident to self-management their COPD
Why- Not given the resources or skills required
Why- Clinicians are unaware of self-management strategies available and how to refer
Why- Not clear local referral pathways available or defined service/clinician roles
Why- No mechanism to encourage collaboration and/or a team approach to patients with COPD
 Narelle
Include summary of diagnostics including project integrate and process mapping
Stakeholder and relationship analysis, 5 whys
Talk about only 7 responses and not sure who has responded and the influence on results.
1. Person-centred care: ability to empower and engage: positive, room for improvement around health data access
2. Clinical integration – care coordination around people needs: room for improvement - more people disagreed with this
Professional integration - areas for improvement include shared accountability, collaborative agreements
Organisational integration - not everyone knows what goes on in the organisations - alot of neither agree nor disagree
Systemic integration - workforce is the main issue
Functional integration - some quick wins we could make with communication
Normative integration - positive response - shared vision

5. Narelle
Other diagnostic activities to be undertaken

6. 4. Analysis and design (logic map)
100% of patients diagnosed with COPD will be linked with self management strategies within 12 months of diagnosis
Summa
Mel
The Core Aims and Objectives of the Integrated Care Project / Program (What?)
Map current COPD/respiratory care services, including pulmonary rehab and early intervention programs
Identify current roles and linkages between COPD/respiratory care services (community and primary care)
Identify gaps and areas for improvement
Develop linkages between primary care and community based COPD services
Improve referral of patients to rehab programs including early intervention programs
Ensure equitable access to pulmonary rehab services

7. 4. Potential Process Measures
Number of GP’s using COPD HealthPathways
Number Health Literacy sessions held by the practice
Number of times the COPD has been viewed
Patient knows who to ask about particular elements of their care
Number of patients identified who have been referral onto self-management services
Level heath literacy has improved
Number of patients and times the action planned was implemented
Number of people who attend education session of brief smoking cessation.- Post training survey to measure confidence
Number of patients who present to ED with exacerbation
Number of patients who received a brief smoking cessation intervention
Number of care plans developed
Number of sick day action plans developed
Number of patients who cease smoking
Number of partnerships developed
Number of patients/carer who receive written and verbal information regarding COPD and self management options i.e. Pulmonary rehab, QUIT smoking hotline
Success of partnership- VIC partnership tool
Measure patient experience
Communication pathway developed
Feeling better equip to self manage- partners in health scale
Number of clinical conversation had within the team i.e. number of calls received from GP
Measure patient outcomes- CAT tool
Measure QoL- find tool
Number of practices that develop a MDT meeting
Feel more supported to be the patients carer
Number of MDT meetings held
Feels more confident to be the patients carer
Number of shared care plans developed as a result of patients discussed at MDT meeting
Number of practices who are providing in GP based Pulmonary rehab
Number of referrals received from GP other other MDT members
Number of enrolments in GP based Pulmonary Rehab
Number of patients identified
Number of patients who complete GP based Pulmonary Rehab
Number of patients who access self-management strategies- defined by service
Patients feel confident to ask questions about their illness
Clinician and service satisfaction
100% of patients diagnosed with COPD will be linked with self management strategies within 12 months of diagnosis
Summa
Mel
The Core Aims and Objectives of the Integrated Care Project / Program (What?)
Map current COPD/respiratory care services, including pulmonary rehab and early intervention programs
Identify current roles and linkages between COPD/respiratory care services (community and primary care)
Identify gaps and areas for improvement
Develop linkages between primary care and community based COPD services
Improve referral of patients to rehab programs including early intervention programs
Ensure equitable access to pulmonary rehab services

8. 5. Mission statement
The philosophy guiding our project centres on inclusiveness, self-management and improved patient outcomes.
100% of patients diagnosed with COPD will be linked with self management strategies within 12 months of diagnosis
Sue
Mel
The Core Aims and Objectives of the Integrated Care Project / Program (What?)
Map current COPD/respiratory care services, including pulmonary rehab and early intervention programs
Identify current roles and linkages between COPD/respiratory care services (community and primary care)
Identify gaps and areas for improvement
Develop linkages between primary care and community based COPD services
Improve referral of patients to rehab programs including early intervention programs
Ensure equitable access to pulmonary rehab services

9. 6. Action plan and time line
Timeframe
Engagement
Define partners
Hold workshops
Define Governance structure and secure Executive sponsors
Patient/consumer input on COPD collaborative
Patients together to do journey mapping
1-3 months
Planning
Co-design with partners
Identify existing and new resources
Investigate funding models
3-6 months
Implementation
Work with General Practice to implement strategies define through the co-design process
9-12 months
Create a list of key actions that your group think would be necessary in order to be able to take forward and or maintain integrated care
Summarise these on a paper – this may be used for your final feedback on Thursday
Mel

10. Thankyou
Murrumbidgee PHN gratefully acknowledges the financial and other support from the Australian Government.
The Primary Health Networks Programme is an Australian Government Initiative.