To demonstrate how a specialist respiratory physiotherapy service placed in the community can prevent unnecessary hospital admissions in patients with COPD.
A city wide multidisciplinary team with a large cohort of physiotherapists and lead by a physiotherapists were introduced to support patients with COPD in their own homes.
Glasgow continues to have the lowest life expectancy in the UKwith 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. 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.
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. 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.
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 six Band 7 physiotherapists led by a Band 7 physiotherapist.
The team, working to Scottish standards for COPD, 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 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 reported 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 city wide project:
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 these 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. This includes 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.
Cost and savings
Over 1400 patients have been supported through the project with an average referral rate of 88 patients per month. The summary of the financial savings are as follows:
- 45 patients at risk / month of hospital admission are managed at home,
- Financial saving £1,068,780 to £1, 692,564 per annum
- Cost of the Community Respiratory Team is £605, 000 per annum
- Net savings of £463,780 to £1,087,564 per annum produced.
The team has had a positive impact on primary care by freeing up GP time. The team particularly supports patients in deprived areas, who traditionally do not engage with primary or secondary care. It delivers home pulmonary rehabilitation to a patient group that are known not to engage with this service.
Hospital admissions rates from COPD were from the area that is covered by the Community Respiratory Team (Glasgow City) with the area of the health board that is not at present covered (Clyde localities). The sectors covered by the service demonstrated that total admissions from COPD were down by 1.5% compared with non CRT sectors admissions that were up 2.5%.
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.
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.
Future development of a 7-day service with extended working hours and independent prescribing would maximise the results already demonstrated.
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 Kings Fund also advocates supported self management to empower patients through improving coordination and integration of services to meet the mental, physical and social aspects of patient care.
The project is highlighted in the Scottish Government COPD: Best Practice Guidelines (2017).
Ensuring the dissemination of practice through relevant respiratory, self management and physiotherapy forums will continue other areas to learn from the project.
Top three learning points
1) 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
2) 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.
3) 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.
Scottish Government Integration Care Fund
- 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
For CSP members:http://www.csp.org.uk/professional-union/practice/evidence-base/outcome-experience-measurement/eq5d5l
- 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
COPD Gold Guidelines
Person centred work, evaluation and making changes to practice
Hospital at home: COPD Care
Integration, prevention and anticipation of Long Term Conditions
Scottish Government Best Practice Guidelines
Contact details for this work: Marianne.Milligan@ggc.scot.nhs.uk
Updated by the author in November 2018.
First published on the database in 2017.