COPD Patient and carers Therapies inc pulm rehab Intermediate care team Social Worker Respiratory Physician EAW/General Physician Case manager/ Community Matron GP Disjointed, duplication Wasted resources Poor pathways of care Patient not seen in most appropriate place Pathway for COPD patient in Wolverhampton 2011 Tele- medicine Hospital at home team Palliative care Practice nurse Oxygen service Ambulance service A&E

Patient Integrated care system Good use of resources Robust pathways Patient seen at appropriate place Prevention Early diagnosis Treatment Communication Self care Education Partnerships of care Specialist review Convenient follow up Palliation Chronic care model Integrated care pathway

No more silos Rainbow feeds into DDG Commissioner present at monthly meeting Robust data feed New Cross manager integral part Chief operating officer sponsors lung improvement program

Respiratory In Reach 7 day service Consultant led but multidisciplinary Potential benefits – Reduced length of stay – Improved diagnosis – coding and triage – Better initial treatment – Improved mortality – Standardised discharge bundle - reduced readmission rate – Improved patient experience.

HOT Clinic Innovative Consultant delivered daily admission avoidance clinic Open access including self referral Conversion rate currently < 15% But…….? timely OPEN ACCESS TO HOT CLINIC Respiratory Centre New cross Hospital (Monday to Friday only) To arrange an urgent appointment. phone before 11am If your respiratory condition deteriorates Telephone

MDT Fortnightly multidisciplinary meeting 30 day readmissions discussed + open access for all members of RAINBOW Primary care represented through community matrons Palliative care consultant and CBT trained physiotherapist in attendance Actions plans produced and communicated

Community clinics Clinic delivered in heart of high prevalence area (low DNA rate) Improved understanding of issues facing GP’s (and vice versa) Raises respiratory profile and builds credibility of RAINBOW in general practice Facilitates finding the missing millions

Other services in place for COPD patients Well established and efficient HOSAR Hospital at Home Quality assured spirometry GPWSI Pulmonary rehabilitation in 4 areas

p = 0.11