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

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 2015-16, respiratory hospitalisations in MPHN accounted for 6.2% of the total hospitalisations (7472/120512). This equates to a rate of 2683.3 per 100,000 (NSW 1731.3 per 100,000). Of all the PHNs in NSW, MPHN had the highest rate of respiratory hospitalisations. In 2015-16 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 2473.8 per 100,000; NSW 1462.8 per 100,000). As for COPD deaths, there was an average of 118.5 per annum in MPHN between 2014 and 2015. 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.

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

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

Narelle Other diagnostic activities to be undertaken

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

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

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

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

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