The First Integrated Respiratory SpR April March 2014 Working across primary and secondary care boundaries Melissa Heightman, SpR to Dr Myra Stern

Talk Plan  Case study  Why develop such a role?  How was the position approved  What the job involved  Lessons learned  Discussion

Integrated Respiratory at WH  Whittington Health: Integrated Care Organisation  2 integrated respiratory consultants commissioned by CCG (Dr Myra Stern/ Dr Louise Restrick)  Promoted by the British Thoracic Society  Aligned with Trust Policy  Working across acute & community care sites  3 PA’s : Enabling, Up skilling and Collaborative Work, Community Respiratory (CORE) MDTs, LES for COPD  2 PA’s – Strategy and Service Development

Integrated Respiratory Physicians Original Aims & Objectives Coordination and integration of respiratory care between primary and secondary care sectors. Providing medical leadership to the multi-disciplinary team (COPD admission avoidance, early discharge schemes, pulmonary rehabilitation and oxygen assessment services ) Earlier diagnosis of COPD Improved quality of care and optimisation of treatment. Supporting high quality pulmonary function assessments in the community. Acting as a learning resource for respiratory medicine for GPs and practice /community based nursing staff. Mentoring GPs with an interest in respiratory disease Evaluating the development of outreach clinic models. Developing a strong multidisciplinary team including psychologists, social care, clinical nutrition and palliative care. Developing and evaluating integrated pathways for managing patients with complex breathlessness in the community; Promote better end of life care for those with severe lung disease Developing new services and ensuring high standards for those receiving home oxygen. Developing new services for patients with diffuse parenchymal lung disease, Working with London Ambulance Service to optimise ambulance transfers. Promote good respiratory health (tobacco avoidance, exercise, clean air and the avoidance of obesity.) Working closely with quit smoking teams across primary and secondary care.

Integrated Care - priorities  Holistic, patient centred care  Support self management  Co-ordination of hospital & community care  Implementation of evidence based guidelines  Disease prevention & promotion of (lung) health  Promote earlier diagnosis (COPD)  Commissioning of integrated consultants has improved delivery  Award winning

Value of an Integrated Service  Measuring value is complex- best exampled by LES  25% increase in diagnosed COPD prevalence, 2010 – 2013  93% increase in referrals to pulmonary rehabilitation,  72% of people on COPD register now have self management plan  16% decrease in COPD emergency admissions

Integrated SpR role approval  Dr Myra Stern  15 years experience to pass on  Bid to training committee (SAC)  2010 respiratory curriculum "Managing Long Term Conditions: Integrated Care and the Promotion of Self Care”  Appropriate mentor and job plan  Liaison with TPD to identify suitable individual  Supernumerary position  I was persuaded!- unique opportunities/ mentor

 60% full time unbanded supernumerary  Job plan: optimise integrated experience / meet PYA requirements  1 day: ambulatory care or acute medicine  1 day: “community”  CORE MDT Islington/ home visits/ GP practices  Shadowing Dr Stern  1 day: respiratory inpatients/ outpatients Job plan

SpR: Integrated projects SpR Nurse Champions Pathways in AEC ILD clinics/ integrating ILD Service development Supporting self management Pulmonary rehab/ Singing! Weekly CORE MDT + audit/ database GP/ home visits,social services Horizontal integration

Community Respiratory (CORE) MDT  Team = Consultant, physio, psychology, RNS, social services  Discussed complex cases/ new referrals  I learnt:  How to lead/ support MDT  Not line managers!  Appreciating their skills  Understanding their challenges. Sick patients! Difficult areas: -clinician excluded from the management structure – challenging to influence to achieve change -imperfect communication with GP/ acute trust/ within team - overlapping catchment with other trust with less integrated philosophy -some duplication of input with other services/ specialties -GP / patient presence preferred but ? achievable

GP visits  Requirement of LES: 1 x visit per practice per year  Content driven by GP preference: Case discussion/ presentation  Value of face to face content and open forum  I learnt:  better appreciation of GP workload  variation in standards between practices  GPs don’t always see value in specialist input!  patient experience in primary care  importance of practice nurses  Who should drive integration? How to coordinate efforts?  Lots of schemes with overlapping aims but no contact = confusion

SpR: Integrated projects SpR Nurse Champions Pathways in AEC ILD clinics/ integrating ILD Service development Supporting self management Pulmonary rehab/ Singing! Weekly CORE MDT + audit/ database GP/ home visits,social services

Champion  Funded by Islington LES, COPD  Open to practice, district, prison and care home nurses  Lectured in educational sessions  Mentored respiratory projects  Vital role in patients with long term conditions  Improve standards, share learning, network Nurse Champions

Home visits  For complex housebound patients  Visited with CORE team case manager  Requests from AEC/ hospital at home or by GP  Diagnostic review  Fuller understanding of complex issues  Reasons for non concordance  Other issues impacting on care  Provide link between GP, patient, hospital, social services  Resource saving sometimes?

SpR: Integrated projects SpR Home visits Pathways in AEC ILD clinics/ integrating ILD Service development Supporting self management Pulmonary rehab/ Singing! Weekly CORE MDT + audit/ database GP/ Nurse Champions

Ambulatory Care  Useful vantage point to integrate with acute medicine  Part of AE, next to GP service. Now 12 bed unit  Respiratory cases booked for my days  Knowledge base/ spirometry skills  Understanding of respiratory referral pathways  Continuity for presenting at MDT  Avoid duplicate OP reviews  Up-skilling other doctors (reciprocal)  Designed a pathway for AECOPD

 Patients seen in AE/ refered AEC by GP  Fit for discharge  Pathway for  Diagnostic confirmation  Treatment optimisation  Referral to CORE team  Respiratory review

SpR Nurse Champions Pathways in AEC ILD clinics/ integrating ILD Service development Supporting self management Pulmonary rehab/ Singing! Weekly CORE MDT + audit/ database GP/ home visits,social services SpR: Integrated projects iPad database COPD strategy Future Hospitals Kings Fund Integrated Service for ILD ADP

Service improvement  iPad database app for community record keeping (wifi synch)  More efficient entering and sharing of information between GP/ acute service and respiratory medicine  Liaison and approval from hospital IT  Ability to audit/ greater transparency of activity of service/ better clinical governance

SpR Nurse Champions Pathways in AEC ILD clinics/ integrating ILD Service development Supporting self management Pulmonary rehab/ Singing! Weekly CORE MDT + audit/ database GP/ home visits,social services SpR: Integrated projects iPad database COPD strategy Future Hospitals Kings Fund Integrated Service for ILD ADP

My impressions  Hugely beneficial year  Re-energised after “old school” training  Many novel training experiences  Enriched my practice and perceptions  First chance to be involved in service development  Excellent mentoring  Ideal transitional role to consultant grade  A little conflict with service provision requirements  Ideally part of all rotations- a necessity not just a luxury?

The future of the post  Deanery in agreement pilot successful  SpR no. 2 has started (in job share)  70% of NE trainees expressed interest  Also interest in NW and S Thames in similar posts BUT  Registrar positions not all filled in NE Thames  No more supernumerary jobs  OOPE? Or embed in to rotation with more similar positions  Enough mentors?

Relevance to other specialties?- paediatrics, care of the elderly, renal, endocrine Reciprocal training for GP trainees with long term condition clinicians? How to coordinate all of this integration? Kings Fund “commissioning and contracting for integrated care” Nov 2014 Discussion