Hospital at Home Dr Catherine Monaghan Belinda Peckett Amy Wynne Trust Member Event Wednesday 21 June 2017 Hospital at Home Dr Catherine Monaghan Belinda Peckett Amy Wynne

Hospital at Home Background to the service Patient journeys Key Performance Indicators Added value Where next Patient experience

Hospital at Home MDT delivered, consultant led service Delivers care at home for patients with exacerbations of COPD across the CCG Provides a full package of care tailored to an individuals’ needs Offers both early supported discharge and admission avoidance

Background Hospital Admissions for Exacerbations of COPD (Per 1,000 COPD Registers): 146.9 Mean Length of Stay in Hospital for COPD interventions: 5.94 days Cost of Hospital Interventions for Exacerbations COPD (£ Per 1,000 COPD Registers) : £ 298,164 approx. £2.2M spend per year

Background Hospital Readmissions within 30 Days: 20.6% Emergency admissions are increasing year on year: 780 in 2005/6 1,000 in 2012/13 1151 in 2015/16 *Data collected from NEPHO 2013

During an acute admission Patients do not necessarily see a COPD specialist There is evidence of deconditioning and loss of muscle mass Admissions are not necessarily good for patients Psychological detriment to patient

Hospital admissions with COPD Why do patients need to be admitted: If they are seriously unwell and need emergency oxygen or ventilation Why are patients admitted when they don’t need to be: Because there is (was) no alternative

Offers a serious alternative to an acute admission Hospital at Home Offers a serious alternative to an acute admission Provide acute care at home for patients with exacerbations of COPD Consists of a multidisciplinary team of experienced health care professionals doctors, nurses, physiotherapists, HCAs Service available 8am-8pm 7 days/week The hospital at home service comprises a team of health professionals who are experienced in caring and treating patients with breathing problems. The team is comprised of Doctors, nurses, therapists and health care assistants who will provide timely, safe and effective care and treatment to patients with Chronic Obstructive Pulmonary Disease (COPD) within their own home and, or community setting who are experiencing severe breathing difficulties The purpose of the service is to treat patients with COPD in such a way that they do not need to go into hospital for treatment and / or to help patients to return home more quickly following a stay in hospital following severe breathing difficulties. Envisaged a 7 day service 8 - 8

H@H Referral criteria: Known COPD Increased SOB Increased sputum Increased cough

Exclusion criteria • Unconfirmed diagnosis of COPD • New Hypoxia with SaO2 <88% on room air • New or worsening oedema • Acute confusion • Impaired level of consciousness • Central Cyanosis • Respiratory rate >24 • Pulse Rate >125bpm • Significant chest pain • Hypotension BP <90/60 • Rigors

Referrals Referrals accepted from different health care professionals: GP Community matrons Accident and Emergency NEAS Acute trust Rapid response

Self referral Patients can self refer if they have already been through the service

How to refer Fax referral to SPA Phone SPA SPA then task the team directly Patients can phone the SPA and self refer into the service

What the service offers A home visit within 2 hours of referral being received Comprehensive assessment by a professional with expertise in COPD An individual Programme of care tailored to each patients specific need

What the service offers Support and care at home Medical interventions; Nebulisers Antibiotics Steroids Chest physiotherapy Sputum clearance techniques Symptom management Inhaler advice and technique Medicines management

Every patient is offered: A full review of treatment Advice on smoking cessation Referral to pulmonary rehabilitation A written plan as to how to self manage their COPD A six week consultant follow up review A phone number to call if they become unwell again Signposting to other services: D/N, palliative care, Dietician

Safety Access to a respiratory consultant 9am to 5pm Monday to Friday for advice One hour per day of rapid access slots with a respiratory consultant A weekly MDT A six week follow up appointment

Patient Journeys Dorothy T

Dorothea W

Gloria

What our patients receive Comprehensive assessment from respiratory practitioners with advanced respiratory skills. Treatment prescribed and issued in accordance with patients symptoms and clinical findings. Weekly discussion at MDT

On going management and support from the team with no time limits, based on clinical need. Multidisciplinary working, working along side other health professionals to make every contact count including close links with NEAS High standard care delivered with compassion

Open and honest communication with our patients around disease management and disease progression. Health education and promotion.

Pre service criticisms and our experience so far “patients won’t like this, they want to be in hospital” “this is potentially unsafe, what if a patient is really unwell” “what if the diagnosis isn’t COPD?” “you will get a lot of referrals for patients that don’t need to be in hospital” “GPs won’t use this: its easier just to admit a patient”

Key Performance Indicators Referrals received: 1684 New patients seen: 1535 Home visits: 5210 Inappropriate referrals: 120 Acute admissions: 60

Other data Mean length of stay has reduced by 17% Admission avoidance is difficult to measure exactly: we think about 60% of the patients referred into our service would otherwise have been admitted this leads to a 33% reduction in the number of admissions we would have expected

PDSA PDSA in November 2016 Between 8am-8pm every GP who wanted to admit a patient with COPD was asked if they wanted to refer them to the H@H team instead We admitted zero patients with COPD that week from GPs

Referrals into service

Added value Ensuring diagnosis is correct Optimize medical treatment Medication to reduce risk of future exacerbations Optimize inhaler treatment Making sure patients are on the best and most cost effective inhalers Signposting to appropriate services

Patient experience Patient survey

Patient experience Always helpful and never rush Could not ask for better treatment 100% better than being admitted to hospital I have never known care like it Best service I have ever come across We need this team: I will never be afraid if I’m poorly

Summary Refer all patients with an exacerbation of COPD who meet the criteria Send referral via the SPA Team will visit within 2 hours: 8am-8pm 7 days a week We will provide a full programme of care

Patient experience Patient experience Video https://youtu.be/lYJjC5uol7A Very powerful for campaign care closer to home for NHS England.

Where next? Further work with NEAS Strengthening links with GP practices Doing practice visits and case reviews, at request of CCG Expand the number of conditions we cover bronchiectasis

Where else can we use this model? Frail elderly Nursing and care homes Heart failure

Thank you