>>Amy: The challenge that we set ourselves was to improve the speed of referrals, of
patients from the secondary care team to the community care team, once they’ve been discharged
from hospital so that was COPD patients who had been in hospital for an exacerbation of
COPD to ensure that the referrals were sent to the community team within seven days of
discharge. The second part of that was to ensure that these patients were followed up
at home by the community team within 48 hours, so in follow up we mean, a phone call done
within 48 hours and then a visit planned based on the outcome of that phone call. Our overarching
aim was to reduce readmission rates, so at that time, the readmission rates for COPD
patients who had been discharged from that hospital were quite high, probably the main
reason why was because the speed at which the referrals went from the secondary care
team to the community team was often quite delayed because we didn’t have very a good
structure or a very good communication pathway or referral pathway in place. So, our overarching
aim was to try and reduce those readmissions by using the resources that were already in
place.
>>Jacqui: The challenge that our team have looked at, have looked at reducing referral
rates for patients over the age of 60 with a diagnosis COPD to secondary care by 50%
and we’ve looked at 3 themes of how we’re going to achieve this. One of - the main theme
was looking at the referral process used by GP practices and we’ve developed a pathway
which the GPs in CCG are happy to pilot, and we’ve worked closely with secondary care.
Then, we’ve also looked at patient education within our organisation, within our team,
we do provide pulmonary rehab, but it is unfortunately - t’s a long waiting list due to demand
and capacity we have. And one of the practice nurses within the 100-day challenge had said
about an education program for patients from diagnosis. So, we’ve piloted 3 patient education
programmes within our organization, these have been well attended and well evaluated
by patients and their carers and one of the comments I can remember is that they should
be available to all patients with COPD and long term, that is our aim: that it should
be available to all patients with COPD. Then the final part, looking at out of hours referrals
to our service and to secondary care, because it’s quite a lot of patients with COPD who
attend out of ours whether it’s always appropriate or not, it’s maybe because they can’t
get a GP appointment. So, we’re working with our out-of-hours colleagues and we’ve
got an education session at the end of the month which will look at the pathway and providing
them with a referral proformer to refer into our service if it is appropriate.
>>Amy: I think what the 100 day challenge has flagged up to all of us who were involved
on our team is the importance of recognising the resources that are already in place, recognising
the teams and the services which were already in place and utilising those for the benefit
of everybody who’s involved, so making it a bit of a symbiotic relationship between
the two. Our team already covered that area, we already had a team in place, there was
no extra resources required. There was already a nurse working in the in-patient unit in
Chelsea and Westminster hospital who already picked up these patients, so everybody was
already in place. So, for me, and for our whole team, the biggest thing we wanted to
do was to make sure that we were utilising everybody that was there for the benefit of
the patients. What we have achieved is we have really managed to reduce readmission
rates, but I think, even more important than that, we have built a relationship between
the two teams now. The nurse who is involved with the Chelsea and Westminster team, who
works in the ward, she talks to my team very regularly. She will ring us, if we have any
issues, our team will ring her, so it’s also allowed us to develop and progress the
relationship ultimately between the team and the community care team. We’re picking up
referrals really early so therefore we can make meaningful interventions with the patients.
It’s beneficial to the team within Chelsea and Westminster hospital because its reduced
readmission rates and therefore, in the long run, it’s going to help not just the hospital
but the nurse who’s looking after these patients. And then it’s also beneficial
for the patients themselves.
>>Jacqui: Obviously, long term, referrals to secondary care or to our service will be
more appropriate in a timely nature as well.
>>Amy: The most useful and most powerful thing I’ve discovered through the 100 days is
the power of opening communication with somebody. How important it is to get all relevant stakeholders
for a problem actually sitting down at a table together, over a couple of hours, and discussing
what the issue is and coming up with simple solutions for the problem. Setting a project,
sitting down with all relevant stakeholders, coming up with a joint plan together and also
making sure you review those plans. Our community-based patients will often be admitted to the hospital
of Chelsea and Westminster, so by opening up communication between those healthcare
professionals who see the patients within the hospital and the healthcare professionals
who can see the patient in their home is the biggest impact. The feedback we’ve had from
the patients was how reassuring it was for them, once they go home from the hospital,
to have another healthcare professional get in touch with them a couple of days later
and say, ‘this is my number, I can come see you at home or I can talk to you on the
phone’ which isn’t a service that someone in an acute setting can provide. So, it’s
giving patients support and reassurance that even after they’ve gone home from hospital,
that there’s still people who can understand their condition, who can treat their condition,
who are still available for them to talk to and to link in with, even when they’ve been
sent home from hospital. We also want to expand that to other services,
between our service and the Chelsea and Westminster hospital, so we’re going to meet up with
some of the other acute teams: the pulmonary rehab team and see if we can again continue
to expand our relationship. Given that our services cross the same geographical sites
of Chelsea and Westminster, we often have patients who go between the two areas or the
two services, so it’s just continuing to develop that relationship as much as we can.
>>Jacqui: It was key to get key stakeholders involved, so there were stakeholders involved
from primacare, obviously from our community service, from secondary care. We also had
a patient representative and their carer come along to events and the different elements
of the projects we’ve set up have gone into different parts of the COPD pathway, looking
right from diagnosis, looking at the importance of empowering patients, getting them on appropriate
treatment and to reduce exacerbation rates and referrals to secondary care.
In these early stages, the patient education program, I think, has had the biggest impact
on patients and their carers because that’s very much about the patients being involved
in that process. And we’ve been able to, you know, from the evaluations, that they’ve
actually increased their knowledge and their confidence in managing their disease. So,
that is initially, having that huge impact on patients, but also, working with other
services across the country and sharing our experiences, sharing our ideas, which is so
important.