Rising Risk COPD Winter Project, Cornwall

Project overview, including who was involved in the project

We identified rising risk COPD patients with 3 Primary Care Networks (PCN's). These patients were then cross-referenced with the Integrated Community Respiratory Team (ICRT) and secondary care respiratory consultants to ensure the cohort was clinically appropriate. This process also supported improvements in coding accuracy within primary care and ensured that the appropriate services were invited to participate in our "Super Saturday" health and wellbeing events, particularly relevant given that 27% of the cohort had not received vaccinations. Further analysis enabled us to determine IMD scores for the cohort, assess housing types, and identify any reported housing-related issues. Patients were subsequently invited to attend the Super Saturday events, which aimed to address both clinical and wider determinants of health. At these events, we provided:
• Clinical Interventions: OPTIMISE reviews, vaccinations, respiratory physiotherapy assessments, pulmonary rehabilitation demonstrations and referrals, onboarding support for MyCOPD, referrals to Virtual Care for supported self-management (with escalation pathways to virtual wards and wrap around community services if needed) and opportunities to address other Quality and Outcomes Framework indicators through the "Making Every Contact Count" approach.
• Holistic Support: Mental health services (where appropriate), benefits reviews, food and heating vouchers, heated blankets, damp and mould toolkits, and digital inclusion support.
• Community Engagement: Peer support groups, introductions to local exercise programs and Healthy Cornwall, and one-off PHBs to facilitate access to pulmonary rehabilitation services.
• Virtual care support was strengthened through using MyCOPD; however, patients who were non app users were not excluded. Our respiratory management plans for this cohort reflected this flexible approach to digital engagement.

Who was involved in this work/project?
- Cornwall and Isle of Scilly ICB
- Three PCN's
- Two secondary care trusts
- One Community Trust
- Public Health- Health and Housing
- Local Authority- Inclusion Cornwall/Healthy Cornwall/Community Energy Plus/benefits/winter warmer homes
- Mental health support workers/community health and wellbeing workers
- Voluntary, Social and Community Enterprise (VSCE)
- Peer support groups
- MyMHealth

Project outcomes/impact

• Enhanced Multidisciplinary Collaboration: Strengthened partnerships across health services, local authorities, and housing providers, fostering more integrated and coordinated care.
• Improved Clinical Coding: Achieved greater accuracy in primary care coding, supporting better patient identification and care planning.
• Establishment of Peer Support Networks: Successfully launched two new “Breathers” peer support groups
• Pulmonary Rehabilitation Completion: Achieved 100% completion rate for all patients referred to pulmonary rehabilitation.
• Empowered Self-Management: Increased patient engagement in self-supported management through virtual care tools, including MyCOPD.
• Streamlined Escalation Pathways: Improved community-based escalation processes for patients experiencing exacerbations, enhancing access to timely and appropriate healthcare.
• Addressed Wider Determinants of Health: Tackled key social and environmental factors, including digital exclusion, to support holistic patient wellbeing.
• Positive Feedback: Received excellent feedback from both patients and staff, highlighting the value and impact of the initiative.

If you were to run the project again, what would you do differently?

• Start the project earlier in the year so the Super Saturdays would have been held in the run up to the winter months, coinciding with the Council’s Winter Wellbeing Events
• Timed appointments worked best rather than drop-in sessions- 48% attendance compared with 25% attendance
• Had representation from Virtual Care at the Super Saturdays- people wanted to be able to recognise the voice on the end of the phone
• Increased use of our expert patients and VCSE to promote the events
• Address the did not attends (DNA’s)- using VCSE and personalised care approaches “What matters to me”
• Link with Department of Work and Pensions WorkWell Scheme- 50% of working aged people with COPD in Cornwall remain in work, 50% do not

Advice you would have for others undertaking the same type of project.

• This was a whole system approach- find your key players- there are so many people trying to do the same thing, grow your tribe!
• Make sure you have support from your Integrated Care Board.
• Actively engage with your Neighbourhood Teams
• Use your data analysts to track outcomes