The Community Respiratory Team supports patients living with Chronic Obstructive Pulmonary Disease (COPD) in their own homes. They work with patients to improve self management of their condition and enable activity and enhanced quality of life when living with this long term condition.
The project has resulted in shorter hospital stays, due to home based rehabilitation for COPD patients.
Glasgow continues to have the lowest life expectancy in the UK1 with COPD being the only major cause of death in Scotland which is rising. In Glasgow you are 45% more likely to have Chronic Obstructive Pulmonary Disease than in any other part of Scotland with the condition accounting for 45,000 emergency bed days annually due to exacerbations or “flare ups” of the condition.2 It is estimated that there are 100,000 people in Scotland living with COPD, with a predictive increase of 33% in the next 20 years.2
The National Institute for Health and Care Excellence (NICE) recommends a community multidisciplinary team approach to the care of patients with COPD to maximise self management and reduce the burden of disease.3 Evidence demonstrates effectiveness in hospital admission avoidance schemes, with respiratory clinicians supporting the unwell patient within the home setting, as a safe and effective alternative for GPs to utilise.4
Scottish Government legislation embodies the drive to support people in their home setting, focussing on integration of health and social care maximising anticipatory self management to allow the person a full and positive life in their own home.
The aims of the Community Respiratory Service are:
- To avoid unnecessary, unscheduled hospital admissions by treatment of the patient suffering from an exacerbation of COPD in the home setting as an alternative to hospital admission.
- To facilitate the early discharge from hospital, working closely with the Early Supported Discharge team and inpatient colleagues to reduce length of inpatient stay.
- To reduce future hospital admissions by providing a person centred approach to care maximising and enabling the self management of people with COPD.
Following a smaller scale, 2 year pilot in one area of the city which had shown robust evidence for improved health outcomes, a city wide physiotherapy-led multidisciplinary team was funded and established. The team comprises nurses, occupational therapists, dietitian, pharmacy and health care support workers and is supported by sessions from a respiratory physician. The service included 6 Band 6 physiotherapists led by a Band 7 physiotherapist with one rotational Band 5 from the acute setting.
The team, working to Scottish standards for COPD5, adopts a person centred approach to give people with COPD the knowledge, skills and resilience to self-manage their COPD. This includes providing specialist input e.g. breathlessness management, airway clearance techniques, optimisation of inhaled therapies, anxiety management, equipment provision and practice of daily tasks, improvement in activity levels by provision of home pulmonary rehabilitation, medication review, and signposting to community services such as befriending and local community social classes.
The ethos of the multidisciplinary service surrounds the collaborative effort between the patient and the clinician to produce person centred goal setting and working towards an individualised outcomes approach which has been shown to increase participation and engagement. Over 80% of patients produce their goals which they then score at the end of the intervention in terms of their success. Examples of goals include: “To feel more confident with my breathlessness and have less panic attacks when out walking to my local shop every day” or “Know how to clear the phlegm from my lungs to help my breathing in the morning time”.
The start date of the project was April 2015 with data being collected and reported quarterly as part of the Integration Fund Requirements. The project is being run until March 2018 with the pilot results and first year results being reported in this document.
Additional research results will be available in January 2017 with our intervention group being matched to a patient population that would be eligible to receive the service but are out with the geographical catchment area of the team. This will look at indicators of health such as number of hospital admissions between the intervention and control group.
An initial pilot was undertaken in the North West of Glasgow for 2 years beginning in January 2013 and funded through the Scottish Government Change Fund. The results were presented at a key stake holder event with representatives from patient groups, health professionals and clinical leads from primary and secondary care together with representatives from the 3rd Sector. Through demonstration of robust evaluation and audit, and through positive feedback from this event, a successful submission for further funding through the Scottish Government Integrated Care Fund was achieved.
This allowed the service to expand the specialist multidisciplinary approach and increase its coverage across the city. In addition the team received sessional input from a Secondary Care Respiratory Physician through weekly multidisciplinary meetings enabling a full specialist multidisciplinary review of the COPD patient within the primary care setting.
The pilot demonstrated statistically significant improvements in terms of reduced impact of the disease and quality of life through the use of validated outcomes measures pre and post intervention. This involved the COPD Assessment Test (CAT)6 and the EQ5D5L measure7. Qualitative research through semi structured patient interviews also supported the implementation with notable benefits including: 1) value of knowledge of who to contact when unwell to prevent a hospital admission; 2) enhanced ability to self manage their condition mainly breathlessness, related anxiety and sputum clearance and 3) improved confidence in activity levels and ability to access community services.
Engagement sessions with all relevant parties e.g. presentations at GP forum events and to a variety of acute staff were key for the introduction of the city wide service with SPARRA (Scottish Patients at Risk of Readmission and Admission) data analysed to enable specific GP practises with high levels of COPD to be targeted.
Specialist Staff recruitment, development and training was fundamental to providing a safe and effective respiratory service within the community. This included University courses for on call staff enabling physiotherapists and other clinicians to work at a Senior Practitioner level; supervision sessions with senior staff; targeted education sessions with Clinical Specialist staff and a Respiratory Physician; Competency Framework and achievement of Disease Specific NHS Education for Scotland module qualifications. Staff commitment towards delivering this standard of care required was exceptional.
The service provides a home support service and targets a more severely impacted, housebound patient group with 90% of the patients categorised as 4 or 5 on the Medical Research Council Breathlessness Score (Level 5 indicating they are breathless when dressing and undressing). The aim with the service was to support 75- 100 new patient referrals per month across the city with a strong emphasis on admission avoidance.
After the pilot, the service was established in the North West at the onset of the project in April 2015. A gradual introduction across the city was planned in line with recruitment, with the service successfully being established subsequently in September in the North East Sector and in the South Sector by December.
Cost and savings
Previous initial pilot in the NW of Glasgow city demonstrated a reduction in hospital admission by 60%.
We estimated our cost-savings on national data; the cost of an average length of stay in hospital for COPD patients in Glasgow8was £3,000 and across Scotland, the cost of an inpatient spell within a speciality for someone with COPD ranges from £1,895 to £3001 depending on the severity and any co morbidities (SIMD 2013/20149).
The total cost of the city wide physiotherapy lead multidisciplinary team is
£605,000 per year.
122 patients at risk of hospital admission to date have been supported in the community with an estimated cost benefit of between £231,190 - £366,122. On average 12 patients per month at risk of hospital admission are referred into the Community Respiratory Team mainly through their GP. An anticipated potential annual cost benefit of between £272,880- £432,144 can therefore be predicted due to an avoidance of a hospital admissions.
In addition, the service is now established and patients known to the service now self-refer for support in the community when they have an acute exacerbation as a rapid management and an admission avoidance strategy. In a given month this can approximate 35 patients which equates to further savings of between £66,325 and £105,035 per month.
In conclusion the total annual cost savings through admission avoidance is calculated to be £1,068,780 to £1,692,564 per annum.
There are expected additional cost savings of GP time due to the fact that patients who have an exacerbation now directly contacted the service early in their unwell episode (before they become at risk of hospital admission) this is estimated at @35 per month
Feedback from patients was very positive, both in their ability to manage their condition more effectively, to personal comments.
Patients were able to self-manage their condition more confidently and effectively in the community setting.
- “The girls were nice really helpful, they said you make a goal. I aimed for 6 weeks and I did it in 3. I wasn't in control of it before and now I'm good. I'm not so hemmed in with it. I've got a bit of my life back. I can get out even without my inhaler always on the go now”.
- " Everything possible to be honest with you, they saved me going to the hospital. They showed me my medication I had been taking I was taking wrong. They fixed all that out. I wouldn't have known what to do without the girls. The physiotherapist arranged for me to get a delta and went over my nebulisers. The occupational therapist arranged for a bath thing for my daughter to help me get a bath ”
- They showed me how to breathe if I was going into panic and that's been a great help. Now I know how to stop that. I live alone and if I went into one of those panics I wouldn't be running about thinking I'd drop dead. You've got to sit, calm yourself and it'll all come back”
Physiotherapists are ideally suited to enable patients to feel more confident in their own self management of their condition through teaching breathlessness management and airways clearance techniques, providing rehabilitation, improving knowledge and working towards person centred collaborative goal setting. Links to third sector ensure continued improvements in quality of life and self management.
Similarly physiotherapists possess the necessary skills and knowledge to react, assess and treat the acutely unwell respiratory patient safely within the home setting to avoid an unnecessary hospital admission.
The main barriers included recruiting a large team on temporary funding basis and streamlining the service with other existing respiratory services (hospital based respiratory nurses and pulmonary rehabilitation) to ensure agreed referral criteria for all community respiratory services and constructing a seamless pathway for all patients and referrers.
An additional barrier was the engagement of referrers e.g. GPs into the service. Experience of the service, establishment and increased knowledge through targeted engagement sessions addressed this.
The challenge of setting up a safe and effective service as an alternative to hospital admission was addressed by ensuring development, training, guidance and a support system to clinicians was in place. Shadowing of other respiratory services across England and Scotland was also beneficial.
Staff were fully engaged in the process and committed to the delivery of the new service to improve the respiratory provision for patients within their own homes. This was crucial to providing a successful service, with the team on board to continually look at the model of delivery of care and its improvement. Patient feedback was utilised at sessions to look at benefits of the service, and where service improvements were needed. Commitment to implementation of service improvements and through tests of change was crucial, with the desire to provide an effective person centred approach being the driving force by all involved.
It is essential to ensure information is effectively disseminated on the new service to all GPs and relevant stake holders with continual dissemination of our practice through poster presentations, platform presentations, magazine articles and appropriate forums.
Future development of a 7 day service with extended working hours would maximise the results already demonstrated.
Top three learning points
- The Office for National Statistics. Life Expectancy at Birth and at Age 65 by Local Areas in the United Kingdom: 2006-08 to 2010-12. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasintheunitedkingdom/2014-04-16
- Audit Scotland. Managing long-term conditions 2007www.audit-scotland.gov.uk/docs/health/2007/nr_070816_managing_long_term.pdf
- National Institute of Clinical Excellence COPD GuidanceCG101https://www.nice.org.uk/Guidance/CG101
- The Kings Fund. Managing people with Long Term Conditions 2010 http://www.kingsfund.org.uk/sites/files/kf/field/field_document/managing-people-long-term-conditions-gp-inquiry-research-paper-mar11.pdf
- NHS Quality Improvement Scotland. Chronic Obstructive Pulmonary Disease clinical standards 2010. http://www.healthcareimprovementscotland.org/our_work/long_term_conditions/copd_implementation/copd_clinical_standards.aspx
- COPD Assessment Test http://www.catestonline.org/
- The EuroQol Group. EQ5D5L; a measurement tool of health status.http://www.euroqol.org/faqs/eq-5d-5l.html
- NHS Scotland Information Services Division. Scottish Tariffs for cross boundary flow costings based on spells within a speciality data 2013/2014
- The Scottish Index of Multiple Deprivation 2013/14 http://www.gov.scot/Topics/Statistics/SIMD
Further information on our service can be found at:
http://theadvisoronline.co.uk/print-issues (Volume 7. Issue 1)
Publications and Guidelines
Standards for Pulmonary Rehabilitation
The following results were demonstrated from the 2 year pilot:
Validated outcome measures utilised to demonstrate effectiveness i.e. CAT scores, EQ5DL-quality of life outcome measures.
A paired sample T test on the CAT score showed a significant improvement (p=0.001) An average change of 5 was achieved, with a change of 2 being noted as being clinically significant.
A paired sample T test on the EQ5DL showed a significant improvement (p=0.000).
80 % of patients were set individualised SMART goals and goal attainment was 85%.
Qualitative data was provided from 58 semi structured interviews. Qualitative analysis of this data indicated the values that the patients found from the service. Patients had increased confidence in how to control their breathlessness and related anxiety, and improved knowledge of physiotherapy techniques to self manage their condition particularly during exacerbations. Patients additionally reported heightened activity levels, resulting in patients being less housebound. They also strongly valued the alternative provision of specialist support in the home instead of a hospital admission.
The following results are from the first year of the current project.
Through the introduction of a city wide service over the year over 600 patients have been supported with an average referral rate of 90 per month (compares with 19 patients referred per month in the pilot).
CAT scores demonstrate an overall improvement of 4 pre and post intervention with on par improvements of quality of life measures as demonstrated in the pilot of improvements of average 13%.
94% of urgent referrals are seen within one working day
76% of urgent referrals did not require a hospital admission, as the rapid (the majority same-day) provision of a specialist multidisciplinary team in the patient’s home allows effective management of the patient on the day, including review, engaging with the patient, educating on self-management techniques such as breathlessness strategies, airways clearance, nebuliser. a safe and effective home service utilised as an alternative to hospital admission.
81% of patients have person centred goals with them. The ethos of the service is to devise goals that are centred around the needs of the patient and written collaboratively with the patient. This was completed with 81 % of patients. Patients score these at the end of the intervention with 100% indicating complete success.
The average attainment patients scored was 76%.
Patients demonstrated improved levels of confidence in their own self management, reduction in the impact of disease, and improvement in activity levels. They also were offered an alternative pathway to hospital admission by receiving safe and effective care within their home setting. Physiotherapist skills and knowledge were enhanced through the acute respiratory assessment, and subsequent treatment of respiratory patient autonomously within the patient’s home. Working within the multidisciplinary team approach, working towards person centred goals with links to the third sector ensure the benefits are continued into the future.