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Integrated care in COPD – the Bath experience
Jay Suntharalingam Consultant Respiratory Physician, Royal United Hospital (RUH) Bath
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Bath & North East Somerset (BANES) PCT
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Where do intermediate care services fit in?
COPD service Secondary care Primary care
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Intermediate care services - ‘teams without walls’1
Primary care IMPACT service Secondary care IMProving Access to COPD Therapies 1Royal College of Physicians, 2003
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Intermediate care services - IMPACT
Primary care IMPACT service Secondary care Accessible Experience Safe Integrated Quality assured Effective
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IMPACT - staffing 1 WTE Band 7 physiotherapist 2 WTE Band 6 nurse
0.5 WTE Band 3 rehab assistant 1 WTE Band 3 administrator 0.2 WTE Respiratory Consultant Primary care Secondary care
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I M P A C T Oxygen assessment GP referral Early supported discharge
Pulmonary rehabilitation Primary care referral Community COPD clinics Secondary care referral Other community services Medication optimisation Self referral
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Bath COPD patients often have multiple admissions
RUH data 2006/7
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I M P A C T Oxygen assessment GP referral All hospitalised patients
Pulmonary rehabilitation Primary care referral Community COPD clinics Secondary care referral Other community services Education & training for healthcare professionals Medication optimisation Self referral
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I M P A C T Oxygen assessment GP referral Early supported discharge
Pulmonary rehabilitation Primary care referral Reduced preventable admissions and improved patient experience Community COPD clinics Secondary care referral Other community services Education & training for healthcare professionals Medication optimisation Self referral
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Reflection Timescale Commitment Logistical issues but…..
Collaborative working rewarding Promising early results
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April – Sept 2010 95 patients accepted for admission avoidance
67 patients accepted for ESD/AD 99 patients accepted for PR 92 patients have undergone oxygen assessments 54 prescriptions unchanged 30 prescriptions altered 8 prescriptions withdrawn
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Acknowledgements BANES CSHCS RUH Bath Claire Bullard Fi Cook
Stella Doble Louisa Ireson Jill Peel Raymond Owens Carol Lacey Dr Gerrit van Rensburg Dr Andrew Alexander Dr Noeleen Foley Dr Adam Malin Dr Vidan Masani Judith Rollason Mark Grover Clare O’Farrell Nicky Ashton
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