Download Specialist Cardiac and Respiratory Services

Bath and North East Somerset
Community Health and Care
Services:
Specialist Cardiac and
Respiratory Services (Adults)
SD46
1.
Introduction
Cardiovascular disease includes a number of conditions that affect the structure or function of the
heart. Heart Failure is one type of cardiovascular disease and it affects approximately 900,000 people
in the UK. It is one of the most common causes of hospital admission and although it cannot be
cured, effective treatment from a community-based service can help make the heart stronger, reduce
symptoms, reduce the risk of flare-ups and allow people to live longer and fuller lives.
Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including
chronic bronchitis, emphysema and chronic obstructive airways disease. COPD is one of the most
common respiratory diseases in the UK and it is estimated that there are more than 3 million people
living with the disease in the UK, of which only about 900,000 have been diagnosed. Although the
damage to the lungs caused by COPD cannot be reversed, effective treatment can slow down the
progression of the disease.
There are currently two community based services for providing specialist cardiac and respiratory
care. These are the:
1. Community Heart Failure Service; and
2. Community Respiratory Service
Community Heart Failure Service
The Heart Failure Nurse Service provides care management for those individuals who have been
diagnosed with chronic heart failure, using specialist nursing skills. The service responds to all
patients on the chronic heart failure trajectory, but primarily those with advanced heart failure.
The Heart Failure Nurse Specialists, in association with a physiologist from secondary care, also
provide a diagnostic service for heart failure through the provision of echocardiogram clinics in the
community. The results of the echocardiogram are explained to the patient and an appropriate
treatment plan is provided for the GP by the heart failure nurse specialist.
Community Respiratory Service
The Community Respiratory Service, also known as IMPACT (Improving Access to COPD Therapies),
comprises a team of multi-disciplinary specialists who have expertise in respiratory medicine, in
particular COPD. The service aims to maximise a patient’s physical and psychological health through
lifestyle advice and education on exercise and breathlessness. The service also provides oxygen
assessments for all adults requiring oxygen in Bath and North East Somerset (B&NES).
2.
Purpose
2.1
Aims and Objectives
Community Heart Failure Service
The purpose of the Community Heart Failure Service is to provide effective and timely health care for
adults with chronic heart failure in order to improve their quality and quantity of life and to reduce
hospital admissions. The service aims to support patients to self-care and to reduce their symptoms,
thereby improving quality of life.
The objectives of the service are to:
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Promote health and empower patients by educating them and their carers about effective selfmanagement techniques which enable independence and promote dignity.
Perform appropriate holistic clinical assessments which incorporate the biological,
psychosocial and spiritual aspects of an individual.
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Provide case management when appropriate which includes assessing the patient using
advanced nursing skills, reviewing when necessary, prescribing medication and facilitating
other health and social care professionals in order to meet the individual’s needs.
Advise on and prescribe heart failure medication regimes in line with NICE Guidelines.
Advise patients and carers on medicines management.
Community Respiratory Service
The purpose of Community Respiratory Service is to provide an Early Supported Discharge (ESD)
and Prevention of Admission (POA) service for adults with COPD. The service also provides
community based pulmonary rehabilitation programmes and an oxygen assessment service for all
adults requiring oxygen in B&NES.
The service aims to provide a multi-disciplinary and integrated approach to both acute and chronic
disease management for patients with COPD so that admissions to hospital are minimised and when
patients are admitted, their length of stay is as short as possible.
The objectives of the service are to:
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3.
Provide a service which will enhance the patient’s quality of life, improve their physical health
and optimise their social and psychological well-being.
Provide a comprehensive and integrated person-centred approach, embedded in both
primary and secondary care.
Provide timely assessment and management in primary care of patients with COPD and all
adult patients requiring oxygen in accordance with national guidelines.
Provide an in-reach service into secondary care to facilitate the early supported discharge of
patients who have been admitted with an acute exacerbation of COPD.
Provide expertise to other health professionals in managing patients with COPD in primary
care.
Provide pulmonary rehabilitation programmes
Improve self-care of people with COPD (including medicines management) through patient
education, advice and support to stop smoking
To deliver an effective and efficient pulmonary rehabilitation programme in order to maximise
the patient’s quality of life.
National/local context and Evidence base
National Context
As a consequence of the drive to manage patients as close to home as possible, more patients with
relatively complex conditions that were previously managed in hospital outpatient settings are being
managed in the community. Additionally the availability of investigations in community settings is
improving. Therefore, specialised community services are required to ensure that patients receive
high quality care closer to home.
In 2008, the British Heart Foundation published a report on heart failure nurses. It concluded that:
“Heart Failure Specialist Nurses improve health-related quality of life in both patients and carers. They
can work across primary, secondary and tertiary care teams, improving communication and resulting
in a more integrated and seamless care pathway for patients. They are in a position to co-ordinate
care and clinically assess patients, take a concise history, adjust medication in response to clinical
status, closely monitor blood chemistry following medication adjustment, and check for clinical and
renal deterioration. They can help patients understand and manage their condition, providing them
and their carers with education and advice about heart failure, its treatment and what to do if they
have a problem. They have a key role in enabling patients and carers to navigate the patient pathway.
Heart Failure Specialist Nurses can extend knowledge in primary care of how to educate, support and
manage stable patients, including up-titration of medications. This can be performed by the primary
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care staff they have trained, and will help keep stable patients out of hospital, while allowing the
specialist nurses to focus on more complex patients with advanced heart failure.”
Respiratory diseases are a major cause of morbidity and mortality and place significant demand on
NHS resources. COPD accounts for a substantial number of deaths in the UK: it has consistently
given rise to between 25,000 and 30,000 deaths each year over the last 25 years with 15% of those
admitted to hospital dying within 3 months of admission, 25% dying within 12 months and 50% dying
within 2 years. In England, COPD is the second most common cause of emergency admissions and
one of the most costly inpatient conditions to be treated. It is estimated that the direct cost of providing
care in the NHS for people with COPD is almost £500 million a year, more than half of which relates
to hospital care. The national aspiration is to reduce the number of people with COPD dying
prematurely. It requires proactive care and management at all stages of the disease, with a particular
focus on disadvantaged groups and areas with high prevalence. The aim is to improve respiratory
health and wellbeing of all communities and to minimise inequalities between communities. A
proactive approach to prevention, early identification, diagnosis and intervention is recommended and
integration is required across NHS, Public Health and Social Care services to achieve the goal of a
positive, enabling, experience of care and support right through to the end of life.
Local Context
In 2014/15, there were 1,595 people in B&NES diagnosed with heart failure. This is a prevalence of
0.79%, slightly higher than the national average.
In 2014/15, 2,795 patients have been diagnosed and recorded on the COPD disease management
register. This is a prevalence of 1.38%. Whilst the COPD prevalence rate in B&NES is low, it is below
the expected prevalence rate and so there are a number of undiagnosed patients who consequently
may suffer from premature disability and death.
4.
The policy context
The following guidance is relevant to both the Heart Failure and Respiratory Service:
 Royal College of Nursing Guidance
 Nursing and Midwifery Council Codes of Conduct and Professional Guidelines and Standards
 Care Quality Commission Regulations
 Compassion in Practice: Nursing, Midwifery and Care Staff – Our Vision (2012)
 Choice in End of Life Care (2015)
 Department of Health: Personalised Care Planning (2011)
 Department of Health: Supporting people with long term conditions to self-care: An NHS and
social care model to support local innovation and integration (2005)
Community Heart Failure Service
The following guidance is pivotal to the delivery of the Community Heart Failure Service:
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National Institute of Clinical Excellence (NICE) Quality Standard: Chronic Heart Failure in
Adults (2016)
NICE Guidance: Chronic Heart Failure in Adults – Management (2010)
NICE Guidance: Hypertension in Adults – Diagnosis and Management (2011)
European Society of Cardiology Clinical Practice Guidelines: Guidelines for the diagnosis and
treatment of acute and chronic heart failure
However, this is not an exhaustive list and the service should be provided in line with other relevant
guidance.
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Community Respiratory Service
The following guidance is pivotal to the delivery of the Community Respiratory Service:
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British Thoracic Society (BTS) guidelines
NICE Quality Standard: Chronic Obstructive Pulmonary Disease in Adults (2016)
NICE Guidance: Chronic Obstructive Pulmonary Disease in Adults – diagnosis and
management (2010)
However, this is not an exhaustive list and the service should be provided in line with other relevant
guidance.
5.
Service Delivery
5.1
Community Heart Failure Service
5.1.1 Service Model
The Heart Failure Service provides specialist nurse intervention for adults with chronic heart failure.
There are two aspects of the service; heart failure management and heart failure diagnosis.
Heart failure nurses deliver advanced nursing skills through proactive individualised care to patients
identified with chronic heart failure. This care aims to slow down the disease process, control
symptoms and for those who have decompensated heart failure, prevents hospital admission. The
length of time the nurse specialist is involved with the patient is not limited. Where necessary, the
nurse specialists will case manage individual patients to ensure care is holistic and co-ordinated.
Specialist assessment is provided by the heart failure nurse specialists who work in collaboration with
the patient and carer to develop a holistic, individualised treatment and management plan. This
follows agreement of goals with the patient and carer and facilitates individual choice, recognising the
patient as an expert in their own illness. Specialist clinics for assessments and reviews are held in
three locations across B&NES but housebound patients are seen in their home.
The diagnostic service provides rapid access in the community to an echocardiogram which provides
information to diagnose heart failure. Treatment can then follow, delivered by either the team or the
GP. The diagnostic service must adhere to the national waiting time of an appointment 6 weeks from
referral for echocardiogram.
The service accepts referrals from health or social care professionals and self-referrals from service
users already known to the service.
The service provides advice, support and education to other health and care professionals as
required.
5.1.2 Service Development - Opportunities and Issues to be addressed
During 2015/16, the demand for echocardiograms increased significantly resulting in waiting times
increasing beyond 6 weeks. The current service is being asked to provide extra echocardiogram
clinics but there is a shortage of physiologists which is limiting the additional clinic capacity.
Therefore, there is an opportunity to review how clinics are run to ensure that the demand is met
without exceeding the 6 week waiting time.
There is also a lack of cardiac rehabilitation in the community in B&NES so there is an opportunity to
consider whether this should be provided.
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5.2
Community Respiratory Service
5.2.1 Service Model
There are four elements to the Community Respiratory Service which are as follows:
1. Early Supported Discharge
The service triages and assesses inpatients who can be discharged early and supports them at home
for up to two weeks. The number of visits over this period will vary depending on the patient’s needs
but support will cease for the majority of patients after these two weeks. However, there will be a
small number of patients where support cannot be terminated and these patients will transfer to the
maintenance element of the service. At the 4-week post discharge from hospital review, the patient
may be signposted to other services such as pulmonary rehabilitation or smoking cessation.
2. Maintenance / Prevention of Admission
The service supports patients requiring intervention to prevent an admission or to manage their
symptoms on an ongoing basis. Patients are assessed and a treatment plan is agreed. Most patients
receive support for two weeks and are then discharged, having been signposted to other services
such as pulmonary rehabilitation and smoking cessation as appropriate. However, patients can rerefer themselves at any time. There will also be some patients who cannot be discharged due to the
severity and complexity of their disease and co-morbidities and these patients should be visited
intermittently to prevent hospital admission. Nebulisers may be issued to some patients to support
their medication compliance and therefore their breathing.
3. Pulmonary Rehabilitation
The service provide Pulmonary Rehabilitation programmes which combine physical exercise sessions
with discussion and advice on lung health in order to support patients in managing their symptoms.
Currently, eight programmes run each year with a maximum of 12 patients per course. Each patient’s
progress is recorded using objective and subjective outcome measures and at the end of the
programme the patient is discharged back to their GP and made aware that they can self-refer again
at any time.
4. Oxygen Assessments
The service undertakes oxygen assessments for patients who require either short-burst oxygen, long
term oxygen or ambulatory oxygen. Patients are referred by receipt of a Home Oxygen Order Form
(HOOF) completed by a GP, respiratory physician or other health care professional.
The service will provide a specialist review of home oxygen orders and efficient management of
oxygen therapy, this will include the following:
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Develop and maintain clinical and information governance arrangements for home oxygen
assessment, management and review for B&NES CCG registered patients.
Receive requests for home oxygen therapy and review as appropriate.
Ensure appropriate assessment, education and ongoing clinical review of patients prescribed
oxygen therapy in line with national guidance.
Implement robust arrangements to avoid oxygen initiation at the start of the patient journey
where relevant.
Implement robust arrangements for monitoring oxygen costs in relation to ambulatory
supplies.
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Review oxygen register and determine priority list for clinical review and/or change/removal of
home oxygen.
Educate primary care professionals in order to reduce the numbers of inappropriate oxygen
prescribing.
Undertake ongoing telephone contact with oxygen patients to ensure annual clinical review
for the purpose of detecting need for change/removal of home oxygen and record outcomes.
Implement arrangements for visiting patients, including home visiting, for annual clinical
review.
Identify, resolve and report Serious Untoward Incidents (SUIs) regarding home oxygen
provision.
5.2.2 Service Development - Opportunities and Issues to be addressed
During 2015/16, the Community Respiratory Service, working in partnership with secondary care,
started providing interventions to patients with non-CF bronchiectasis. Whilst the success of this
arrangement still needs to be evaluated, there is potential to expand the Community Respiratory
Service to provide interventions to people with other respiratory conditions.
6.
Whole system relationships
Providers of specialist cardiac and respiratory services will need to develop and maintain constructive
working relationships and links with a range of relevant staff and organisations as part of a ‘whole
system’ and integrated approach to care. This includes the encouragement of timely referrals and use
of an integrated approach with other health care professionals and providers.
Systems and processes must be in place to ensure collaborative working with primary care,
secondary care, social care and all relevant professionals to avoid patients falling through the gaps
between services.
The clinicians providing these specialist services must also be able to advise, support and educate
other health care professionals in the management of these conditions so that the patient is fully
supported.
7.
Interdependencies and other services
Both services rely on effective good working relationships with other health and social care
professionals, but particularly GPs and secondary care, so that everyone is in the best position to
offer the best care for the patients. The services should have arrangements with the relevant
secondary care consultants to refer patients on urgently if necessary.
For both services, referrals are made to and from a wide range of health professionals including GPs,
secondary care doctors, community matrons, district and practice nurses, social services and healthy
lifestyle service such as smoking cessation.
The services require access to information held on the patient record systems in secondary care in
order to enable staff to work with the maximum amount of pertinent information.
Finally, the Community Respiratory Service also needs to maintain an effective working relationship
with the oxygen provider.
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