Heartbeat: Integrated care brings significant benefits to respiratory patients
September 5, 2018
A project aimed at providing integrated care to respiratory patients in primary and secondary care has had national recognition as well as tangible outcomes for our patients.
Arvind Rajasekaran, Respiratory Physician led the Future Hospitals Project which aimed to test models of integrated care in conjunction with the Royal College of Physicians. He said the project was about trying to establish how to balance out the respiratory expertise across secondary and primary care.
He explained more: “Respiratory care involves the management of 30 or more conditions. An ageing population means respiratory conditions coexist with significant systematic diseases such as mental health, social isolation, cardiovascular illness and obesity. Managing these conditions requires expertise and skill and care is very often delivered in the community – but the perception is that the expertise lies in secondary care.
“We engaged the key stakeholders involving colleagues in primary care, community and secondary care. Crucially we involved third sector organisations such as British Lung Foundation as well as patients and carers.”
The team held an engagement event to assess what ‘good’ integrated care would look like – this resulted in three work streams being developed to enable:
- Better management of patients in the community
- Early expert involvement in admissions
- Reduction in the use of ED.
As a result, integrated clinics were established within the community setting. Arvind explained that the plan of action involved:
- Initial co-located clinic with a local GP consortium (Tower Hill, Birmingham)
- Respiratory consultant holding clinics alongside a GP for one morning a week
- Obtaining and analysing patient feedback and acting on it to determine any changes to the service.
Arvind said: “This work has seen a significant improvement in the quality of care and financial savings in terms of the care for patients. Some of the key outcomes included the upskilling of GPs who found it beneficial to learn from consultant colleagues enabling them to provide improved care to patients.
Patients were satisfied with the care they were receiving resulting in the reduction of the use of ED.
“Junior doctors also benefitted from the early input of a consultant in the care of their patients, leading to a reduction in the length of stay.
“We enhanced the care bundle provided to the patients admitted with respiratory conditions by setting up processes enabled by collaborative working by the hospital based nurse specialists and community based respiratory nurse specialists.”
The work the team has done has received welcome recognition at the national level and they have enjoyed a tremendous amount of support from within our organisation, Sandwell and West Birmingham Clinical Commissioning Group and colleagues working in primary care and community.
Arvind added: “The real success lies in scaling this up to ensure the benefits reach the entire population that we serve. So in some ways this is an ongoing piece of work with the focus on continuous improvement of respiratory health.
“Our Trust vision is to be renowned as the best integrated care organisation in the NHS and true to that vision, we are in the process of establishing the governance structure that will enable the clinical teams to provide integrated respiratory service to the entire population living within the boroughs of Sandwell and West Birmingham.”