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

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 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.

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

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

Narelle

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

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