1. Respiratory Service Framework Asthma and COPD Care (Nursing) Project Learning and Development Strategy

2. Service frameworks are defined as being measurable, evidence–based standards which are the product of a process of engagement with HSC staff, service users and the public. Each Framework will follow the individual’s journey, from prevention through to end-of-life care, taking account of all aspects of health and social care providing an opportunity to promote evidence-informed practice with a focus on safe and effective care. Template for the Development of Service Frameworks for Health and Social Care Department of Health, Social Services and Public Safety, 2007.

3. What is a Service Framework?  Explicit standards on prevention, treatment and care  “Quality requirements” supporting the standards  Specific timeframe - 3-5 years and revision process  Capable of measurement/comparative data  Linked to the HSC quality standards and other policy, documents and guidance  Applicable to both adults and children  Follow a life cycle approach  Developed in collaboration with the HSC and public.

4. Patient/ client Pathway Template Prevention / Promotion Protection /Lifestyle Treatment Ongoing Care / Chronic Disease Management End of Life Care / Palliative Care Assessment & Diagnosis

5. Overarching Standard 6.1.1 All people suspected of having COPD should have accurate assessment, diagnosis and management in Primary Care. Rationale COPD should be prevented where possible, but, as a minimum, disease progression should be slowed down or avoided by early diagnosis and optimal management in keeping with the most up to date evidence based guidelines. Evidence  National Institute for Clinical Excellence (2004) Management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Institute of Clinical Excellence: London http://thorax.bmj.com/content/vol59/suppl_1/  Strategic Framework for Respiratory Conditions (N. Ireland), 2006. http://www.dhsspsni.gov.uk/pcd_-_respiratory_framework.pdfhttp://www.dhsspsni.gov.uk/pcd_-_respiratory_framework.pdf Responsibility for delivery / implementation HSC Trusts Primary Care Quality Dimension 1.All patients older than 35 years, with past/present smoking history, and presenting with exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis or wheeze should have spirometry performed. 2.All patients with a diagnosis of COPD should have an assessment and review according to NICE guidelines 3.All patients suspected of or diagnosed with COPD should have their smoking history recorded and be given appropriate advice about smoking cessation and specialist smoking cessation services. Performance IndicatorData SourceExpected Performance Level Date to be achieved by Percentage of patients with COPD who smoke, who have had appropriate smoking advice DES Data set Audit of GP records 60% 80% 90% March 2010 March 2011 March 2012 Percentage of patients with COPD who are assessed, diagnosed and managed according to NICE Guidelines in primary care. DES dataset Rolling audit of GP records 60% 80% 90% March 2010 March 2011 March 2012

6. How will they be assessed? Service Audits Patient Registers QOF data sets DES data sets PAS Evidence collected by organisations to support achievement

7. Current Work Cardiovascular Disease Respiratory Wellbeing Cancer Mental Health Learning Disability April 2008 May/ June 2008 July 2008

8. The Future of COPD Nursing Care The RSF Standards

9. Communication Patient Education Location of Care Health Technology Multidisciplinary Working

11. Prevention / Promotion Protection /Lifestyle Modifiable Risks Smoking Cessation/ Prevention – Specific Targets Smoking Reduction Smoking Reduction Lifestyle assessment Physical Activity Planned Programmes Education – Medication compliance and efficacy Patient Partnership Patient Partnership Negotiating a plan of care and lifestyle adjustments

12. Assessment & Diagnosis History Taking Airflow Limitation – SPIROMETRY Accurate, interpreted Accurate, interpreted Screening – Symptomatic smokers Registers

13. Treatment Self Management – Face-to-face care planning Written copy Written copy One core written plan One core written plan Acute Exacerbation – Early Supported Discharge Resp. Physician Resp. Physician Emergency Oxygen – Alert cards BTS Guidelines BTS Guidelines NIV – Management of NIV Case Management – Expertise in Co-morbidities

14. Ongoing Care / Chronic Disease Management Telemonitoring – 50k patients in next 3 years Pulmonary Rehabilitation – MRC 3+ offered referral Monitoring uptake Monitoring uptake Programme Development and access Programme Development and access Nebuliser Therapy – Assessment for Equipment – Compressor/ O2 Equipment – Compressor/ O2 LTOT – Adherence to Assessment Criteria Ongoing Monitoring – Annual Review/ ½ yearly Case Management

15. End of Life Care / Palliative Care Key Worker – Core Palliative Care Competencies Early Needs Assessment – MRC 5 Trigger Questions Trigger Questions Patient Choice Supportive and Palliative Care Register Breaking Bad News - Communication

16. The Future of Asthma Nursing Care The RSF Standards

17. Communication Patient Education Location of Care Health Technology Multidisciplinary Working

19. Modifiable Risks Smoking Cessation/ Prevention – Specific Targets Maternal Health/ Parental Health Maternal Health/ Parental Health Lifestyle assessment – Allergy Triggers Physical Activity Education - Medication compliance and efficacy Patient Partnership Health Inequalities – Immigrant Populations Electoral Wards Electoral Wards Prevention / Promotion Protection /Lifestyle

20. Assessment & Diagnosis History Taking - One airway (allergic Rhinitis) allergy testing allergy testing Diagnostic Therapy Trial Diagnostic Therapy Trial Airflow Limitation – SPIROMETRY Accurate, interpreted Accurate, interpreted

21. Treatment Self management – Face-to-face care planning Written copy Written copy One core written plan One core written plan Anaphylaxis Management – Register Allergy expertise Allergy expertise Acute Exacerbation – Treatment as per Guidelines Review and Follow-up – Admission A&E A&E Non-admission Non-admission

22. Ongoing Care / Chronic Disease Management Review – Frequent admissions Early Follow up Early Follow up Appropriate Referral – Difficult to Control Asthma Alert Cards – Education Inhaler Technique Allergy History - Testing