Population Health Management Approach to Respiratory Care, Gloucester Inner City PCN
Project overview, including who was involved in the project
The aim of the project was to co-produce a data led approach to respiratory care; that proactively manages patient care and leverages all available resources (positively impacting patient health, reducing utilisation costs and patient admissions). To apply context, we have some of the highest rates of social deprivation and smoking in the country. 56+ different languages are spoken.Following a service evaluation in our primary care network (PCN), we reached out to 27 stakeholders, collaborating their knowledge and opinions to leverage collective expertise and resources. We then designed a Respiratory Whiteboard (WB): a risk stratification tool that includes clinical markers in Asthma and COPD (based on current respiratory guidelines) to define and allocate patients into Red, Amber and Green groups (RAG system).
1. The RED patient group were used to identify patients appropriate for the PCN respiratory team.
2. The WB was used to identify patients who would benefit from an appointment with the specialist respiratory physiotherapist for breathlessness management (in a collaborative project with Sue Ryder).
3. The WB facilitated the identification of patients for our partnership with Gloucester City Homes Tenancy and the Warmth on Prescription programme.
4. The data from the WB helped us develop and create an innovative approach to address tobacco dependency and inequalities (see more information on social deprivation below). We hired and trained an in-house Stop Smoking Coach who speaks Polish/Slovak/Czech/English.
5. We matched the level of care of our respiratory nurses (by using the PCRS Fit to Care tool) to the RAG system to ensure that patients matched the right level of clinician.
Social deprivation: significantly higher than average levels of smoking, mental health, children on Marac (multi-agency risk assessment conference) or safeguarding lists, multi- morbidity/chronic diseases (respiratory +obesity/diabetes highest prevelance), higher than national average prevalence of respiratory disease (asthma and COPD). Solutions: we did joint multi-disciplinary teams (MDTs) with respiratory consultant/practice nurses/mental health advanced clinical practitioners (ACPs). Our PCN then used the risk stratification approach for diabetes and CVD as well as developing a bespoke weight management service. We hope to do joint MDTs for patient on both the RED respiratory and diabetes lists this year.
Who was involved in this work/project?
• PCN Respiratory Team
• (Polish/Slovak/Czech/English speaking) Stop Smoking Coach
• Respiratory Specialist Nurse Lead,
• Respiratory Specialist Nurse,
• Care Co-ordinator
• Secondary care Respiratory Consultants
• Practice staff
• Sue Ryder Physiotherapist
• Integrated Care Boards (ICB) (provided project management support in the second phase)
• Local stop smoking services
• Other PCN's
• Business Intelligence
• Local community centre
• Primary Care Clinical Audit Group (PCCAG)
• Gloucester City Homes
Project outcomes/impact
Our evaluation is not complete yet, but we are seeing incredibly positive changes across service usage in primary and secondary care (including OOH and 111 calls). In addition, respiratory prescribing has improved, and patients are reporting better symptom control. The following are some of our measured outcomes that have been achieved:1) Improvement in ACT between 20-25 in 60% of asthma against a baseline of 38%
2) Reduction of RED risk asthma patients with =/>6 SABA from baseline 92% to 72%
3) Reduction of patients with >/=2 OCS in last 12 months to 40% for Red Risk COPD against a baseline of 50%
4) Business Intelligence helped us to capture our patient cohort service usage We are in the process of formally evaluating these results but so far there is a promising improvement seen in the following areas:
a) 111 calls and OOH contact: a statistically significant reduction of over 40% in both
b) GP contact: a statistically significant reduction of 8.9 %
c) Respiratory Emergency Admission: a statistically significant reduction of 61.1%
d) Respiratory Outpatients: a statistically significant reduction of 88.7%
6) The health benefits of stopping smoking for the patient must not be underestimated. There have been 150 quit attempts and forty-eight successful quits through our in house PCN service with one part-time coach delivered in English, Polish, Slovak and Czech languages. We also worked with a local community centre and local partnerships to deliver and interactive Wellbeing Cafe for Stoptober, but focusing on 'Breathing Well'.