1. Integrating primary and community care services for improved diagnosis and 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

2. The key issues…
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.
General practice data continues to show poor spirometry rates across the region, leading to delayed diagnosis and poor care planning
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)
Sue
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. Aims and objectives….
To establish an integrated model of care for the management of people with COPD in the community across the Murrumbidgee
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
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. The approach…. Executive support - COPD Collaborative (MPHN & MLHD)
Identify linkages with current activities forming part of the MLHD Leading Better Value Care (particularly with reference to discharge from acute setting)
Patient journey maps (for diagnosis and management and exacerbation) to identify issues and gaps
Identify current roles and linkages between community and primary care COPD/respiratory care services
Identify areas for improvement and possible reorientation of existing resources (including $$) where required
Narelle
Slide 4: The Proposed Approach / Options Being Considered for the Implementation of the Integrated Care Project (How?)
This will be determined throughout the course of the workshop. Patient journey maps (for diagnosis and management and exacerbation) have recently been mapped to identify issues and gaps and provide a broad overview of the services involved in the patient journey. These maps are attached for further information and will be used to inform discussion and planning around inter-disciplinary and inter-professional partnerships

5. Narelle

6. Global issues around integrated care Translating theory into practice
What do we want to learn more about this week…
Global issues around integrated care
How to measure success
Translating theory into practice
Summa

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