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The Role of the Team

Background

 If you live in Glasgow, you are 45% more likely to have Chronic Obstructive Pulmonary Disease (COPD) than any other part of Scotland and accounts for 45,000 emergency bed days costing £9.5 million to the health board annually. COPD can be characterised by frequent and sometimes preventable exacerbations of the condition and admissions to hospital. It is the third most common reason for hospital admission in Scotland and has high readmission rates.

 Scottish Government drivers indicate the need for personalised, community services enabling self-management of long term conditions, shifting the balance of care away from the hospital setting and building capacity within the primary setting. Specialist multidisciplinary respiratory support in the community has been demonstrated to be a safe and effective approach to the management of patients with COPD and is advocated to reduce the burden of disease and improve quality of life.

 

What We Do

 The Community Respiratory Team is a nationally unique service that supports the needs of people living with COPD in their own home and is made up of physiotherapists, respiratory nurses, pharmacists, occupational therapists, dieticians and rehabilitation support workers. GPs utilise it as an alternative to patients going into hospital by accessing the specialist service supporting the patient in their own home. The service also facilitates early discharge from hospital by closely linking with secondary care colleagues and providing responsive follow up and support. The ethos of the service is to provide a personalised approach to care, enabling self-management by the patients including: increasing their own knowledge of their condition and especially what to do when they are unwell; improving knowledge of inhaled therapies; knowing how to clear their chest and also increasing their physical activity and independence through the provision of home pulmonary rehabilitation and equipment. In addition, malnutrition, mental health issues of anxiety and depression, and complex polypharmacy/ comorbidities that are commonly seen in end stage COPD are addressed through the coordinated, multidisciplinary approach. Weekly multidisciplinary team meetings with a respiratory physician facilitate secondary care reviews and investigations.

 After an initial pilot of two years in one area of the city, robust evaluation demonstrated a reduction in the impact of disease, an improvement in patients’ quality of life and a reduction in the number of hospital admissions. Further funding was secured for a Glasgow city wide service in April 2015 through Scottish Government Integration Care Fund for 3 years.

 

Impact of the Team

 A final report published in 2017 (Final Report) demonstrated the progress so far of this 3 year project after the initial pilot. Over 1400 patients have been supported through the service with an average referral rate of 88 patients per month.

 In the year to 31 December 2016 there were 1,051 referrals to the service. If we assume that each inpatient episode is "average" and lasts on average 5.9 days at a cost of £3,100 then if every referral resulted in an admission the annual cost for these patients being treated as inpatients would be approaching £3.3m. This clearly represents a significant cost avoidance within the Acute Division and even if only 20% of these referrals avoid admission then the costs avoided would cover the salary budget of the staff within the Team (currently £644k).Furthermore, the team is receiving from patients (that are known to the service) an average of 20 referrals per month who are also deemed to be at risk of a hospital admission. If these patients were to be admitted as inpatients then additional costs of £744k per annum would be incurred therefore increasing the contribution the Team is making to minimise costs across the NHS system

 The reduced impact of disease and improved quality of life has been demonstrated through validated outcome measures. The person centred approach which adopts a joint goal setting method has enabled patients to achieve increased physical function and improved access to their local community environment. Linking with other agencies has allowed on-going improvements in health.

 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.