Keynote presentation delivered by Dr Irem Patel, Integrated Consultant Respiratory Physician, Kings Health Partners, at the Pan London Airways Network Summer Meeting 2016

1. Integrated respiratory care: what, why, how?
Dr Irem Patel, Integrated Consultant Respiratory Physician
King’s Health Partners
16th June 2016
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily
represent the views and policy of PLAN(Pan London Airways Network).

2. • Definition of integrated care
• Drivers: historical
• Drivers: present
• Current emphasis
• Informing principles
• Models and evidence in COPD
• Roles and skills of an integrated respiratory clinician/team
Learning outcomes: to understand.. Page 2

3. What is integrated care? Page 3
DoH: NHS Next Stage Review 2008
“healthcare professionals working on a collaborative basis with clear leadership,
shared goals, and shared information, designing services around the needs of
individuals and local communities’
King’s Fund: 2012
“an approach that seeks to improve the quality of care for individual patients,
service users and carers (as people) by ensuring that services are well
coordinated around their needs……must impose the user’s perspective
as the organising principle”
BTS: Position Statement on Integrated Care 2014
“the best possible care for the patient, delivered by the most suitable
health professional, at the optimal time, in the most suitable setting”

4. Vertical integration across all healthcare sectors Page 4
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist

5. Vertical integration across all health and social care Page 5
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist

6. Horizontal integration across common comorbidities Page 6

7. Drivers for integration: historical Page 7
1948
With thanks to Professor Martyn Partridge

8. Original structure of healthcare Page 8
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist

9. Original structure of healthcare Page 9
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist

10. Original structure of healthcare Page 10
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist
HOSPITAL
BASED
COMMUNITY
BASED

11. Original structure of healthcare (UK, Canada, Scandinavia,
Netherlands, Australia, New Zealand etc) Page 11
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist
HOSPITAL
BASED
COMMUNITY
BASED

12. Original structure of healthcare (variations in US and some
European countries) Page 12
Patient
Generalist Specialist
Hospital care HOSPITAL
BASED
COMMUNITY
BASED

13. Significant changes in healthcare needs and
delivery have taken place in last few decades,
mostly in:
• unplanned way
with
• unintended consequences
Page 13

14. Significant changes in healthcare needs and
delivery have taken place in last few decades,
mostly in:
• unplanned way
with
• unintended consequences
Page 14

15. Unplanned changes to this model 1990-2015 Page 15
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist SUPER
SPECIALISATION:
Opting out of
General
Medicine

16. Unplanned changes to this model 1990-2015 Page 16
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist Development of
Acute Medicine
and AMU

17. Unplanned changes to this model 1990-2015 Page 17
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist
Acute Physician

18. Unplanned changes to this model 1990-2015 Page 18
Exponential rise in primary care consultations 2000-2008:
Increasing pressure on primary care
Source; NHS Information Centre

19. Unplanned changes to this model 1990-2015 Page 19
Exponential rise in primary care consultations 2000-2008:
Increasing pressure on primary care
Source; NHS Information Centre
Off loading by hospitals
Increasing population
Increasing longevity
Increasing expectations
Changing health burden

20. Changing health burden:
Causes of morbidity/mortality NHS was set up for Page 20
With thanks to Professor Martyn Partridge

21. Causes of morbidity/mortality NHS deals with now: Page 21
60% of global deaths
are due to chronic disease
70%
30%
Total NHS spend England
LTC
Other
LTCs account for:
75% inpatients
65% outpatients
65% primary care OPAs
Murray. Lopez et al Lancet 2005
DoH Long Term Conditions estimates 2010

22. Changes to health care professional roles: nursing/AHP Page 22

23. Changes to health care professional roles: nursing/AHP Page 23
April 1981
The respiratory health worker
With thanks to Professor Martyn Partridge

24. More recently, emergency care further compromised Page 24
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist
No longer responsible
for emergency care

25. Succession of possible solutions Page 25
Patient
Primary care
Generalist
Secondary Care
Specialist
Tertiary Care
Super Specialist
No longer responsible
for emergency care
Out of hours services
Deputising Services
Cooperatives
Walk in clinics
Urgent care centres

26. Unplanned solutions: a vast array of options Page 26
Patient
Doctor
Specialist
Super specialist
Gerontologist
Specialist nurse/physio
Acute Physician
Nurse
Physician
Associate
Nursing
Assistant
Pharmacist
Lay
educator

27. Significant changes in healthcare needs and
delivery have taken place in last few decades,
mostly in:
• unplanned way
with
• unintended consequences
Page 27

28. “Medicine’s complexity has exceeded our
individual capabilities as doctors…
…we’re all specialists now—even primary-
care doctors…
…the public’s experience is that we have
amazing clinicians and technologies…but
little consistent sense that they come
together to provide an actual system of
care, from start to finish, for people….”
http://www.newyorker.com/online/blogs/newsdesk/2
011/05/atul-gawande-harvard-medical-school-
commencement-address.html#ixzz25QFENvfV

29. Fragmented care
Poor patient experience – elderly polymorbid people having
multiple consultations with heart failure CNS/bone
clinic/chest physician/diabetes CNS/pulmonary rehab
physio……
Unwarranted variation in:
• access to care
• organisation of care
• outcomes
Unsustainable system (demoralised workforce)
Unintended consequences: Page 29

30. Workable ideas have come mostly from HCPs rather than NHS managers
Current emphasis on integration Page 30
2014
6 case studies across UK
•Rheumatology
•Child health
•Gerontology
•DM
•Dermatology/minor surgery
•Respiratory
Integrated consultant roles that span hospital
and community settings and include strategic
responsibilities for service planning across
sectors. These provide the capacity and drive
for consultants to work outside the hospital on
top of their usual duties.

31. RCP Future Hospital Program Page 31
Sept 2013
Our vision of the future hospital:
a new model of clinical care
Hospitals will be responsible for delivering
specialist medical services (including internal
medicine) for patients across the health
economy, not only for patients that present
to the hospital.
Much specialist care will be delivered in or close
to the patient’s home. Physicians and specialist
medical teams will expect to spend part of their
time working in the community, providing care
integrated with primary, community and social
care services.

32. Page 32
Oct 2014
“Multispecialty community providers”
As larger group practices they could in
future begin employing consultants or
take them on as partners, bringing in
senior nurses, consultant physicians,
geriatricians, paediatricians, and
psychiatrists to work alongside
community nurses, therapists,
pharmacists, psychologists, social
workers and other staff…
These practices would shift the
majority of outpatient consultations
and ambulatory care out of hospital
settings..

33. Page 33

34. So what is the problem in respiratory medicine? Page 34
2014
Resp diseases affect 1 in 5 people in UK
1 million hospital admissions - £5 billion
3rd biggest cause of death in UK
80,000 deaths/year plus 35,000 to lung ca
Worst mortality cf OECD

35. So what is the problem in respiratory medicine? Page 35
2014
Resp diseases affect 1 in 5 people in UK
1 million hospital admissions - £5 billion
3rd biggest cause of death in UK
80,000/year plus 35,000 to lung ca
Worst mortality cf OECD

36. Page 36So what is the problem in respiratory medicine?

37. Page 37So what is the problem in respiratory medicine?
46% of deaths could have been prevented
65% one or more avoidable factors

38. NRAD: Primary Care Factors 138 GP practices
83% full QOF points for asthma
Time from asthma review to death median 121 (IQR 30-306) days
Where primary care was last asthma review before death: n=135
• 27% had assessment of control
• 42% medication use review
• 71% had assessment inhaler technique
• 24% had a personalised asthma action plan
• 22% missed appt; in 55% practice attempted to follow-up
• 57% not under secondary care in year before death
46% of deaths could have been prevented

39. NRAD: Secondary Care Factors
• 30% in hospital arrest
• 47% had history of previous hospital admission
• 10% died within 28 days of discharge
• 21% had attended ED >1 in previous year
• 68% no follow up after hospital
• 19% had not been referred to specialist care
46% of deaths could have been prevented

40. NRAD: Secondary Care Factors
• 30% in hospital arrest
• 47% had history of previous hospital admission
• 10% died within 28 days of discharge
• 21% had attended ED >1 in previous year
• 68% no follow up after hospital
• 19% had not been referred to specialist care
1 in 5 (23%) were current smokers
36% childhood deaths in smoking families

41. 165 patients where SABA prescription info available:
• 39% had >12/year prescribed
• 6 (4%) had >50/year
128 patients where ICS prescription info available:
• 49 (38%) had <4/year
• 103 (80%) <12/year
5 patients who died were on LABA monotherapy:
• 2 not prescribed corticosteroid and 3 not collecting
39% severe asthma; 49% moderate asthma; 14 ‘mild’ asthma
NRAD: Prescribing factors

42. So what is the problem in respiratory
medicine?
COPD:
• A story with no beginning……
• A middle that is a way of life……
• An unpredictable and unanticipated end……
Hilary Pinnock et al, BMJ 2011; 342
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group

43. Harm and waste due to high dose ICS
98 practices in SE London
41 practices agreed to share data
310,775 patients
3537 patients with COPD diagnosis (1.14%)
IMD score in most deprived quintile of UK
COPD: misdiagnosis, inappropriate Rx and harm

44. 35% of patients on COPD register
did not meet criteria by spirometry

45. COPD: misdiagnosis, inappropriate Rx and harm
Spirometry and exacerbation frequency in
previous 12 months
38% over treated
with inhaled steroids (ICS)
469 patients without
spirometry confirmed
COPD or asthma
= 51% on ICS
•12 additional cases of
pneumonia per year?
•Cost:
£500,000 per year (2 boroughs)

46. Page 46
Price et al. Prim Care Respir J 2013; 22(1): 92-100

47. Hospital care: Ready for home?
British Lung Foundation Patient survey 2010
75% did not feel ready to leave hospital on d/c
37% felt reassured that there would be support at home
34% felt informed about COPD and the reasons for their
admission
31% felt confident their medications were helping
34% confident about spotting early signs of a flare up next
time
25% felt positive about the future
26% delayed getting help/treatment before admission

48. Hospital care: Ready for home?
BLF Patient Survey 2010
Post exacerbation
29% had increased their levels of activity/exercise
35% had renewed efforts to stop smoking
27% had been involved in discussion forum
27% had been contacted by community services
59% had primary care f/u arranged
61% had secondary care f/u arranged

49. Hospital care: Ready for home?
BLF patient survey 2010
Patients would like
75% – more information about reason for
admission
75% – contact from community professionals
69% – practical advice re lifestyle etc
64% – telephone advice/support

50. Cost of treatment for an acute
exacerbation of COPD
O'Reilly et al. Int J Clin Pract 2007;61:1112–20
£110
£1,536
£484
£0
£200
£400
£600
£800
£1,000
£1,200
£1,400
£1,600
£1,800
Medication Hospitalization Other services and
investigations
Treatmentcostforanacuteexacerbation
UK health economy
£810–930 million/yr

51. Cost of treatment for an acute
exacerbation of COPD
O'Reilly et al. Int J Clin Pract 2007;61:1112–20
£110
£1,536
£484
£0
£200
£400
£600
£800
£1,000
£1,200
£1,400
£1,600
£1,800
Medication Hospitalization Other services and
investigations
Treatmentcostforanacuteexacerbation
UK health economy
£810–930 million/yr

52. So what is the problem in respiratory medicine? Page 52
National COPD audit 2014
57% seen by resp consultant during admission
42% managed on resp ward
37% current smokers (32% in 2008 and
40% in 2003)
58% had evidence of smoking cessation Rx
(64% if seen by resp versus 32%)
90% known to have COPD before adm but
46% had spirometry recorded in last 5 years
44% had no assessment of suitability for PR
30% no discharge bundle
38% access to PR within 4 weeks of d/c

53. Informing principle 1= value
Informing principle 2 = right care
Do the right things
Do things right
www.rightcare.nhs.uk
So…….what are the solutions? Page 53
Porter ME, Lee TH.
NEJM 2010; 363:
2477-2481 2481-2483
COPD Value Pyramid: LRT 2010

54. What is high value in COPD?

55. Londoners dying
from smoking
‘1 in 5 deaths due to
smoking’
What is the most important outcome for patients?

56. 0
10
20
30
40
50
60
70
80
90
100
ENGLAND
LONDON
SouthwarkPCT
CityAndHackney…
LewishamPCT
IslingtonPCT
TowerHamletsPCT
NewhamPCT
LambethPCT
HammersmithAnd…
Greenwich…
CamdenPCT
WandsworthPCT
HounslowPCT
KensingtonAnd…
BrentTeachingPCT
EnfieldPCT
WestminsterPCT
EalingPCT
CroydonPCT
SuttonAndMerton…
WalthamForestPCT
BromleyPCT
BexleyCareTrust
HillingdonPCT
HaringeyTeaching…
RedbridgePCT
HarrowPCT
HaveringPCT
BarnetPCT
RichmondAnd…
KingstonPCT
%COPDregisteredpatientswhosmoke(iftheirsmoking
statusisrecorded)
London PCTs QOF
Smoking prevalence in COPD
At best one in four Londoners with COPD are still smokers….

57. Quit smoking as high value TREATMENT for COPD and
therefore a core skill for the COPD specialist
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65:711-718
1 year abstinence
%
QALY
£
Usual care 1.4
Minimal counselling 2.6 14,735
Intensive counselling 6 7,149
Intensive counselling +
pharmacotherapy
12.3 2,092
Tiotropium £7,112/QUALY
Eur J Health Econ.
2007; 8(2): 123135

58. Page 58

59. Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
High value long term care in COPD
PULMONARY
REHAB
NNT = 4 to prevent
one COPD
readmission

60. The right inhaler, first time

62. London Respiratory Team
High value (“right care”) approaches: COPD value pyramid

63. Page 63
“Clinicians need to accept that they are responsible for the stewardship of
resources and not just their use”. Sir Muir Gray BMJ 2012

64. Hospital at Home for COPD
Admission avoidance/Early supported discharge
 Multidisciplinary assessment
 Nursing support at home
 Remain under specialist team
 Cochrane Review 2012:
Reduced readmission rates and trend to reduced mortality
(Jeppesen et al CD003573 DOI: 10.1002/14651858.CD003573.pub2)
Thorax 2007; 62: 200-210

65. Hospital at Home for COPD
Admission avoidance/Early supported discharge
 Multidisciplinary assessment
 Nursing support at home
 Remain under specialist team
 Cochrane Review 2012:
Reduced readmission rates and trend to reduced mortality
(Jeppesen et al CD003573 DOI: 10.1002/14651858.CD003573.pub2)
Thorax 2007; 62: 200-210

66. Models and evidence for integrated respiratory care in COPDPage 66

67. COPD: organisation of care improves outcomes
Guideline based therapy
Regular review – clinical registry
Individualised self management
Advanced access to
knowledgeable HCP
Decision support
Clinical information systems
Improved outcomes
Adams et al. Arch Int Med 2007;167:551–6
Steuten et al Int J COPD 2009;4:87–100
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group

68. Integrated care for COPD
Usual care
Integrated care
Self management education
Individual care plan
Shared with primary care
Access to nurse care manager
12
months
50% reduction in re-admission rates
Improved COPD knowledge, identification
and treatment of exacs and Rx adherence
Casas et al. Eur Respir J 2006;28:123–39
155 patients
FEV1 45% predicted
Discharged from hospital

69. Intermediate care for COPD
Usual care
Intermediate care
Pulmonary rehabilitation
Individual care plan
Monthly phone calls
3 monthly home visits
24
months
Reduced Primary Care Consultations
Increased self management of exacerbations
REDUCTION IN DEATHS DUE TO COPD
122 patients
FEV1 43–49% predicted
Discharged from hospital
Sridhar et al. Thorax 2008;63:194–200

70. Technology assisted integration:
enhanced access
Home rescue therapy
24 hr access to telephone advice
Respiratory specialists; web based
database
258 calls over 20,000 f/u days
45% reduction in admissions
37% reduction in bed days
High patient satisfaction
Hurst et al. Prim Care Resp J 2010;19:260–5
74 COPD patients
FEV1 44% predicted
30% long term oxygen therapy
46% lived alone
‘High risk’

71. Integrated disease management program
for COPD
Usual care
CDM Program
Disease specific education
Action Plan
Monthly follow up calls
12
months
COST BENEFIT:
SAVING $593/patient
743 patients VA USA
Severe COPD
Hx in prev 12 months of
Hospital admission or
LTOT or
Oral prednisolone
Rice et al. AJRCCM 2010; 182(7); 890-6

72. Page 72
“……..it is becoming clear that reliance on individual
management approaches is insufficient to deal with
the complex problems of COPD. In fact, the way that
care is delivered is likely to be more important than
the precise details of what comprises that care..”
PMA Calverley Prim Care Respir J 2011; 20(2): 109-110

73. “a continuum of patient centred services organised as a care delivery
value chain for patients with chronic conditions……
….optimal daily functioning and health status for the individual…

74. Cochrane Review of Integrated Care for COPD: 2014
•26 trials involving 2997 people
•Mean age 68 years, 68% male, mean FEV1% predicted 44.3%
•Healthcare settings: primary (n = 8), secondary (n = 12), tertiary care (n = 1),
both primary and secondary care (n = 5)
•Statistically and clinically significant improvement in disease-specific QoL on
all domains of the Chronic Respiratory Questionnaire after 12 months
•Reduced hospital admissions
•LOS significantly lower compared with controls after 12 months (MD -3.78
days; 95% CI -5.90 to -1.67, P < 0.001)

75. Evolving evidence base Page 75

76. Hospital Care Bundles:
Structured admissions and enhanced recovery
CARE BUNDLES
• Admission an
opportunity for high
value interventions
• Specialist review
• Structured admission
• Make every bed day
count
• Enhanced recovery
• Supported discharge
• Follow up
Southwark Clinical Commissioning Group
Lambeth Clinical Commissioning Group
Nicholas S Hopkinson et al. Thorax 2012;67:90-92

77. Oxygen – doing it right Page 77

78. Advance care planning, avoiding harm Page 78
Patient Specific Protocols
Shared with LAS, ED and GP
Kept at patient’s home
Controlled oxygen
Ventilatory failure
Expression of wishes
Advance care plans

79. Respiratory Virtual Clinics Page 79
Practice
nurse
Respiratory
pharmacist
GP Practice
pharmacist
Respiratory
Consultant

80. Respiratory Virtual Clinics Page 80
Review high value messages
Reiterate referral pathways
Reinforce respiratory
prescribing messages
Review pre-selected caseload
of patients: 20-40
Accurate diagnosis
Appropriate long term management
Complex patients
Relationship building

81. 2014-2015: 94% of practices in Lambeth and Southwark hosted a VC
Evaluation = 4/5 or 5/5
Data from 25 VCs:
• 372 patients on COPD registers reviewed
• 321 (86%) patients had their diagnosis of COPD confirmed
• 279/321 (87%) patients had a recommendation made
• Recommendations included:
64 (23%) referrals to PR
45 (16%) referrals for smoking cessation support
41 (15%) patients to initiate a LAMA
16 (6%) patients to initiate a LABA
198 (71%) patients to step down/withdraw the ICS
Respiratory Virtual Clinics: snapshot data SE London Page 81
D’Ancona GM,, Patel I, Saleem A et al. Thorax 2014;69:A90 doi:10.1136/thoraxjnl-2014-206260.179

82. Outcomes: reduction in high dose inhaled steroid prescribingPage 82
VIRTUAL CLINICS

83. Outcomes: cumulative savings of £350,000 over 7 quarters

84. Outcomes: shift to higher value intervention for a populationPage 84
50% increase in PR referral
from primary care

85. Outcomes: COPD admissions in Lambeth and
Southwark Page 85
KCH – COPD Acute Admissions
HRG Codes 2012-13 2013-14 %change 2014-15 %change
COMPLEX COPD ADMISSIONS
Dz21A 164 164 0.00 192 17.07
DZ21B 1 4 300.00 4 0.00
DZ21E 14 20 42.86 28 40.00
DZ21F 5 4 -20.00 4 0.00
DZ21G 1 4 300.00 0 -100.00
UNCOMPLICATED COPD
ADMISSIONS
DZ21H 124 116 -6.45 96 -17.24
DZ21J 132 120 -9.09 92 -23.33
DZ21K 40 28 -30.00 8 -71.43
Total admissions 481 460 -4.37 424 -7.83
DZ21K Length of stay 2012-13 2013-14
%chang
e 2014-15 %change
DZ21K LOS 4.45 3.41 -23.37 3.7 8.50
DZ21K Admissions 40 28 -30.00 8 -71.43
Total COPD admissions
reduced by 8%
34% reduction in COPD
admissions (without cc)
LOS reduced by 17%

86. BTS position statement 2014 Page 86
Community TB provision
Home mechanical ventilation
Admission avoidance and
Early Supported Discharge for
COPD
Home Oxygen review

87. Summary: Roles of an integrated respiratory clinician/team Page 87
In hospital:
Supporting patients to ‘get better’ as quickly as possible
Act on what matters to patients
Right diagnoses and right treatment – multi-morbidity
Supporting safe transition home
Supporting patients to live better with their long term condition(s)
Planning ahead including taking actions to prevent a next admission
In the community
Supporting accurate diagnosis and high value management (spirometry,
PR, responsible respiratory prescribing, home oxygen services)
Virtual clinics, MDTs
Medical support for H@H and admission avoidance schemes
Accessible specialist advice and ongoing skill transfer
Assessing complex breathlessness
Advance care planning

88. Summary: Roles of an integrated respiratory clinician/team Page 88
In hospital:
Supporting patients to ‘get better’ as quickly as possible
Act on what matters to patients
Right diagnoses and right treatment – multi-morbidity
Supporting safe transition home
Supporting patients to live better with their long term condition(s)
Planning ahead including taking actions to prevent a next admission
In the community
Supporting accurate diagnosis and high value management (spirometry,
PR, responsible respiratory prescribing, home oxygen services)
Virtual clinics, MDTs
Medical support for H@H and admission avoidance schemes
Accessible specialist advice and ongoing skill transfer
Assessing complex breathlessness
Advance care planning
NOT JUST FOR COPD!
BRONCHIECTASIS
INTERSTITIAL LUNG DISEASE
VENTILATORY FAILURE
SLEEP DISORDERED BREATHING
HARD TO REACH GROUPS:
SERIOUS MENTAL ILLNESS
SUBSTANCE MISUSE
PRISONS…

89. Expanded existing skill set
leading a team/within team
multidisciplinary working
teaching, training and communication
service development
improvement methodology
evaluation and sharing learning
Integrated working demands respiratory clinical
expertise PLUS: a new frontier… Page 89

90. A new skill set
leading a team
multidisciplinary working
teaching, training and communication
service development
improvement methodology
evaluation and sharing learning
Integrated working demands respiratory clinical
expertise PLUS: a new frontier… Page 90
Long term conditions expertise
Strong general medicine
Balancing risk – out of hospital settings
Understanding population health
Shared decision making
Collaborative care planning
Motivational interviewing

91. Thank you

92. Possible roles for integrated respiratory specialist Page 92

93. Possible roles for integrated respiratory specialist Page 93

94. Possible roles for integrated respiratory specialist Page 94

95. Possible roles for integrated respiratory specialist Page 95

96. Possible roles for integrated respiratory specialist Page 96

97. Possible roles for integrated respiratory specialist Page 97
PRISONS?

98. Training: already in curriculum Page 98

99. Training: already in curriculum Page 99

100. Training: already in curriculum Page 100

101. Page 101Training: what else is needed?

102. THANK YOU Page 102