The Community Respiratory Team - An enhanced trust wide service offering an integrated pathway for the effective management of patients with respiratory illness within primary care and community settings

摘要

The Community Respiratory Team (CRT) aims to: ? Enhance quality of life and quality of care for patients ? Improve the process of diagnosis and condition management ? Reduce the number of hospital and GP appointments patients require ? Reduce the likelihood of potential hospital admission Based on current evidence-based practice and in line with the principles outlined in Transforming Your Care (TYC), it was recommended that a change to the Trust service model was is required in order to ensure a more co-ordinated and effective service. Transforming Your Care is the programme aimed at changing Northern Ireland’s health and social care system. It is focussed on improving care provided, providing more care at home and less care in hospitals. Under TYC, Integrated Care Partnerships (ICPs) were established to drive improve Integrated working between Primary and Secondary Care services. Evidence indicated that all people with chronic respiratory disease should have access to a Community Respiratory Team that is operating at the interfaces between the Acute Hospitals and the community service and the primary care teams. The CRT was established in June 2015. Prior to the establishment of a CRT, patients with a chronic respiratory disease received care from a diversity of core services (Early Supported Discharge, Case Management, respiratory physiotherapy, respiratory nurse specialists e.g. for oxygen assessment and pulmonary rehabilitation). A multi-disciplinary group was established by the ICP to look at best practice in respiratory care and to examine how to best facilitate the shift to Community and Primary care services. This group identified the requirements to enhance the existing Teams in support of integrated respiratory care pathways. Redesign of existing services was led by a Clinical Co-ordinator and Specialist Nurse. This included networking with key stakeholders through workshops, education sessions with all 57 GP practices in the Western Area, benchmarking against successful integrated respiratory services regionally and nationally, team workshops/meetings to empower staff and encourage collaboration, and an Operational framework developed based on current evidence and up to date guidelines relevant to respiratory disease management. The Operational Plan was circulated trust wide prior to implementation. Timeline : June2015 to date Highlights : Total of 818 patients referred to Community Respiratory Team (August 2015 – March 2016) Total of 7827 face to face contacts (August 2015 – March 2016) 4019 bed days saved for COPD - based on LOS 6 days (August 2015 – March 2016) 739 admissions avoided (August 2015 – March 2016) 3132 telephone reviews (August 2015 – March 2016) The rate of unplanned admissions to hospital for all patients with COPD: 20% reduction. Sustainability and transferability : Well managed change is effective; this includes timely communication and relevant information sharing with all key stakeholders. The individual education sessions with each GP practice was a large resource of time and expertise, this was very worthwhile with excellent feedback in the project evaluation. There is evidence provided, in the feedback, from all groups that the CRT is a provision that has brought positive impacts for patients, professionals and the health service.