Why the community focus?

1. “Assessing and Empowering Respiratory Patients in the Community”A Back to Basics approachfor community based nurses & community pharmacists and for patientsSue Hart, AHSN-NENCRegional Respiratory Programme Lead

2. Why the community focus? • 10% UK population suffer from a chronic respiratory disorder which can be managed in primary care • 90% patient contacts are carried out in general practice • It is estimated that the average person suffering from a long term condition will spend approx: • 5 hours per year consulting a healthcare practitioner • 8755 hours per year managing the condition themselves • A study published in Finland, March 2015 - predicts annual costs for providing care & meds to COPD patients will rise by 60% between 2007-2030

3. Why the COPD focus?

4. Background: Research In 2014 the management in primary care of 3075 COPD patients in Newcastle was audited and compared to NICE Guideline standards. Key findings include: • 63% had no record of exacerbation frequency • 79% had no quality of life measurement • 53% had no inhaler technique assessment • 86% had no self management plan or emergency rescue pack Primary care staff surveys revealed: • 1:4 do not feel confident / adequately trained to advise patients about COPD or to educate on the correct use of inhalers • 1:3 do not feel confident / adequately trained to educate patients on the use of SMPs and exacerbation rescue packs or on the implementation of local treatment guidelines

5. Moving forward: 3 core needs to reduce the COPD burden of healthcare • Give clinicians the skills, knowledge and attitude to motivate patients to self manage • Give patients the skills, knowledge and confidence to manage their COPD • Develop systems to facilitate the above

6. The Respiratory Programme: It’s all about education ….. • Providing back to basics training for “out of hospital” healthcare practitioners • Empowering patients to look after themselves more effectively • Establishing a Primary Care Respiratory Network

7. Three Key Elements: 1. Education Programme - “Assessing and Empowering Patients in the Community”

8. Education Programme Progress: • Pilot programme – 2 sites, 30 places each • Northumbria University: • Delivered Oct / Nov 2015 • 31 delegates attended • Newcastle – 11 (11 P/Ns) • North Tyneside – 5 (4 P/Ns, 1 CM) • Northumberland – 9 (8 P/Ns, 1 CM) • Gateshead – 5 (1 P/N, 1 Care Home, 3 O.T.s) • Durham – 1 (1 Physio) • Sunderland University: • 25th/26th Feb & 8/9th March • 27 delegates registered

9. E-Learning Modules: • 9 short presentations by local HCPs: • Making the correct diagnosis; symptoms and spirometry • Living with COPD: manage the patient not the disease • Regular review of COPD: QOF and beyond • Medication and non pharmacological management of COPD • Oxygen therapy: indications and implications • Inhaler devices in COPD • Inhalation therapy: getting it right • Identification and management of COPD exacerbations • Co-morbidites in COPD: implications for management • Certificated and suitable for re-validation • Accessible via www.ahsn-nenc.org.uk

10. Three Key Elements: 2. Increasing patient’s knowledge • In conjunction with BLF • “Meet the Experts” Patient Awareness Day • Expert Patient Training Events • In conjunction with universities • Incorporating BLF COPD Passport into the curriculum • In conjunction with CCGs • New Breathe Easy groups established • Winter Wellness Workshops – all attendees: • Felt a lot more confident managing their COPD – medication, exacerbations and P.R./exercise • Found sharing experiences with others useful and informative • 100% “excellent” evaluations

11. Patient Feedback: Great from start to finish, please have more This has given me a great deal of confidence Packed full of useful information & a great way to meet other people Very informative and inspiring Knowledge is power, I have learnt a great deal from this meeting At last, a conference just for respiratory

12. Three Key Elements: 3. Primary Care Respiratory Network • Aim to share expertise, innovation and best practice. • Inaugural meeting - Sept 2015 • Consensus agreement: • Need to pursue • Aim to run next meeting - Feb 2016 • Provide a dedicated on-line facility • Development work in progress • Incorporate an Innovations Exchange platform

13. Other stuff: • DDES & Darlington • Newcastle Citywide Project • Aim to reduce the frequency and severity of further exacerbations and hospitalisations: • Patients discharged from hospital within the previous 12 months following COPD exacerbation • Patients at risk of admission i.e. > 3 exacerbations in 12 months and / or FEV1<40% predicted.  • Pharmacy Pilots • Thornfield and Falcon Surgeries • Telehealth • S. Tees Hospital (P.R. step down) • Hambleton, Richmond & Whitby CCG (medication reminders / sats monitoring) • Freeman Hospital (Bronchiectasis) • S. Tyneside (COPD & Heart Failure)

14. Telehealth, South Tyneside: COPD & Heart Failure in Community Nursing Outcomes for patients referred for Telehealth in South Tyneside have demonstrated significant reductions in access to health care: • 53% reduction in attendance at A&E • 55% reduction in Emergency Medical Admissions • 14% reduction in access to Urgent Care Service • 71% reduction in costs associated with A&E attendance and Emergency Medical Admissions

15. The potential impact on the system and patients:

16. THANK YOU ANY QUESTIONS ???