Scottish Health Awards 2015 – Care for Long-Term Illness Award Winners

COPD (chronic obstructive pulmonary disease) Integrated Services Project – NHS Lothian

Long term care

Source:  Daily Record Scottish Health Awards 2015 Supplement

A PDF copy of the supplement can be found here: Scottish Health Awards 2015 Supplement – Page 3

Winners Story:

The Chronic Obstructive Pulmonary Disease (COPD) Integrated Services Project has brought together acute, community, emergency and Out of Hours services to create a Community Based Respiratory Hub.  The Hub ensures patients have access to the right service for them, at the right time and in the right place with a strapline of “wherever and whenever, the patient should have the best service”.

The aims of this project were to integrate existing services of patients with COPD, creating more streamlined pathways, improve patient care, increase self-management skills and reduce unnecessary hospital admissions.  The Hub provides supported self-management through the use of telehealth and became one of the first teams in NHS Lothian to use FLORENCE messaging service to increase adherence to treatment plans.

For GPs and other healthcare professionals dealing with patients who have COPD, the Hub aims to make options for care simple – refer the patient to the Hub via the Community Respiratory Team, and the patient will be considered for all appropriate care both in the community and acute sectors.  This has been supported through communications with all Edinburgh GP practices and referrals into the Hub have increased considerably since the beginning.

The Hub has a holistic approach, with Specialist Respiratory Physiotherapists, Advanced Nurse Practitioners, Respiratory Consultant and Nurses and Pharmacists helping the patient manage their physical illness; while a Clinical Psychologist and Specialist Occupational Therapist support patients to adjust to living with COPD and manage the high prevalence rates of anxiety, panic and low mood.  The Hub also includes Grapevine Disability Information Service, providing financial and social support and signposting to housebound patients with COPD.

The Bigger Picture:

The changes that the Community based Respiratory Hub has made to care and support for patients with COPD have had hugely positive effects for patients, carers and healthcare professionals.  The balance of care has been shifted into the community; patients are activated to self-manage their COPD, supported during acute exacerbations, and given the opportunity to receive psychological and social support.  The integrated approach ensures holistic care and creates an environment for continual professional learning.  This model works and has great learning opportunities for other long term conditions.

This project exemplifies our 2020 Vision for Health and Social Care which states that:

Our vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting.

We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self-management.  When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm.  Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions.  There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

The impact that the Hub has had (since June 2013) is as follows:

  • Saved 1549 respiratory days
  • Case managed 214 frequently attending patients multi-disciplinary team meetings
  • Assessed 242 frequently attending patients by psychology
  • Completed 159 full pharmacy reviews for frequently attending patients
  • Prevented 16 admissions through the new Bed Bureau Pathway
  • Prevented 251 admissions at the Front Door of hospital through Respiratory Nurse Specialists
  • Prevented 18 admissions through the new CRT-SAS Pathway
  • Received 6 referrals from Lothian Unscheduled Care Service (LUCS) Out of Hours
  • Supported 146 extra patients to self-manage using Lite Touch telehealth

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