Transcript Slide 1

CERYS FOLEY
SPECIALIST LEAD NURSE
RESPIRATORY SERVICES
ANEURIN BEVAN HEALTH BOARD
TORFAEN LOCALITY OFFICE
TORFAEN LOCALITY OFFICE
JEAN HUGHSON
LTCT MANAGER
CERYS FOLEY
LEAD NURSE
RESPIRATORY SERVICE
01495 332165
LYNDA DAVIES
LEAD NURSE
HEART FAILURE
01495 332160
SIAN BODMAN
LEAD NURSE DIABETES
01495 332169
MICHELL GRAHAM
CNS
STROKE
TRUST MANAGED/LHB FUNDED
SUE FRANCOMBE
LEAD NURSE
CHD
01495 332159
Trust managed/LHB funded
JACKIE MATTHEWS
CNS
ACUTE RESPONSE/
Early Supported Discharge
COPD
07699622034
CORAL WOODS
Respiratory Nurse
Acute Respiratory Response
Service
TORFAEN LOCALITY OFFICE
LYNDA REES
REHABILITATION NURSE
LOUISE MITCHINSON
CHD NURSE
TORFAEN LOCALITY
Population
190,000
COPD
Prevelence of >2% OR 1,800
ASTHMA
prevalence of approx 10,000 in Torfaen
Accounts for about 28 deaths per year in
Torfaen
DRIVERS FOR SERVICE DEVELOPMENT
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NICE GUIDELINES
DESIGNED 4 LIFE….. Clinical Futures
GMS/QOF TARGETS
OXYGEN CONTRACT 2004
SERVICE DEVELOPMENT and COMMISSIONING
DIRECTIVES FOR CHRONIC RESPIRATORY
CONDITIONS
 PPI
 TORFAEN NEEDS ASSESSMENT
partnership working
TORFAEN LOCALITY OFFICE
TORFAEN NEEDS ASSESSMENT
2006
Develop a better integrated service model that covers
health and social care
.
 service moved away from the traditional model of institutional care and into
care at home.
planned outcomes:
 Fewer unplanned hospital admissions for frail elderly
 More effective use of NHS resources, via a reduction in hospital admissions
 Reduced Delayed Transfers of Care, through increasing capacity in
community services
 Increased independence through Joined up public sector service delivery
and disease specific rehabilitation programmes as well as expert patient
programmes,
…..the right services are provided in the right place, at
the right time and by the right person by refocusing
services and resources to meet local needs………The
provision of services by integrated multi disciplinary and
multi agency teams will also become a key feature of
managing these conditions across primary, secondary and
social care.
Document. Service Development and Commissioning Directives for Chronic
Respiratory Conditions
Edwina Hart. AM. October 2007
TORFAEN LOCALITY OFFICE
AIMS OF TORFAEN
RESPIRATORY SERVICES
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IMPROVED QUALITY OF LIFE
SUPPORT SELF MANAGEMENT
REDUCE NEGATIVE IMPACT ON LIFE
COORDINATE SUPPORT SERVICES
WORK IN PARTNERSHIP
REDUCE ADMISSIONS/LENGTH OF STAY
SERVICES DEVELOPED WITHIN
ALL TIERS OF CONDITIONS
TORFAEN RESPIRATORY
SERVICES
 SPECIALIST NURSE LED CLINICS (Case Management)
 HOME VISITS FOR ELDERLY HOUSEBOUND PROBLEMATIC
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PATIENTS
NEBULISER ASSESSMENTS
OXYGEN ASSESSMENTS
ACUTE RESPONSE RESPIRATORY TEAM
COMMUNITY PULMONARY REHABILITATION
IT IS RECOMMENDED THAT RESPIRATORY
SPECIALIST NURSES FORM PART
OF THE TEAM
NICE 2004
TORFAEN BASED
NURSE LED
RESPIRATORY
CLINIC
COUNTY HOSPITAL
GRIFFITHSTOWN
PONTYPOOL
Target Group
•Patients with a diagnosis of Respiratory Disease which has been confirmed and are
able to travel to the venue of the nurse led clinic.
•Patients with poorly controlled respiratory disease
• Patients who have had 2 or more urgent GP consultations directly relating to their
respiratory disease in the last twelve months or will have had 2 or more admissions to
secondary care with acute exacerbations in the last twelve months
HOME VISITS
 ELDERLY VULNERABLE ADULTS WITH
PROBLEMATIC RESPIRATORY
DISEASE
NEBULISERS
NEBULISER
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Patients with distressing or
disabling
breathlessness despite maximal
therapy should be considered for
formal nebuliser
assessment
NICE 2004
TO DELIVER DRUGS INTO THE LUNGS IN A
MIST OF PARTICLES SMALL ENOUGH TO
REACH THE BRONCHIOLES AND IN SOME
CASES THE ALVEOLI
LONG TERM NEBULISERS SHOULD ONLY BE
PRESCRIBED AFTER ASSESSMENT BY A
EITHER A HOSPITAL CONSULTANT OR
SPECIALIST NURSE IN RESPIRATORY
DISEASE
AIR COMPRESSOR
ACUTE RESPONSE
RESPIRATORY TEAM
Hospital at home
and assisted
Discharge
schemes are safe
and effective and
should be
used as an
alternative way of
managing
patients
Nice 2004
OXYGEN ASSESSMENT
CENTRE
FEB 2006 WAG NEW OXYGEN
CONTRACT STREAMLINES AND
MODERNISES SERVICE
 All oxygen therapy has
to be prescribed and the
percentage stated
clearly
 All patients require CLINICIANS SHOULD BE AWARE
THAT INAPPROPRIATE OXYGEN THERAPY IN
assessment
PEOPLE WITH RESPIRATORY DISEASE
MAY CAUSE RESPIRATORY DEPRESSION
NICE 2004
PULMONARY REHABILITATION SHOULDBE MADE AVAILABLE
TO ALL APPROPRIATE PATIENTS WITH RESPIRATORY DISEASE
NICE 2004
TORFAEN COMMUNITY
PULMONARY
REHABILITATION
An effective short and long term
management strategy for patients
disabled by chronic irreversible
lung disease
Goals of Pulmonary
Rehabilitation
 Improve quality of life
 Decrease respiratory symptoms and complications
 Improving levels of independence and ability to self
manage
 Improve physical conditioning
 Heighten emotional well being
 Reduce hospitalisation
The Torfaen Pulmonary
Rehabilitation Team
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Respiratory Nurse
Respiratory Physician
Cognitive Behavioural Therapist
Physiotherapist
Dietitian
Social worker
Pharmacist
Exercise therapist
Smoking cessation counsellor
Respiratory care
should be delivered
by a multi disciplinary
team
Nice 2004
A LOCALLY BASED SUPPORT GROUP
FOR TORFAEN RESIDENTS AFFECTED
BY CHEST CONDITIONS
Second Tuesday of every month
2.00 pm
Canalside Assessment Centre
Five Locks Road
Cwmbran
NICE guidelines P 26 1.2.18.11
Patients with end-stage COPD require palliative care service
 only 10% of
practices refer
patients with end
stage respiratory
failure to palliative
care
 Liase with palliative
care services to
develop palliative
care pathway for
end stage
respiratory disease
Figure 8 Admission Rates COPD
350
3000
300
300
250
Figure 9 Occupied Bed Days
230
240
260
2510
274
237
2003/2004
2500
2004/2005
2000
200
2005/2006
150
2006/2007
100
2007/2008
50
2008/2009
2400
2000
2116
1800
2007/2008
500
2008/2009
Figure 10 Average Length of Stay
9.1
8.7
7.6
2004/2005
2006/2007
1000
0
8.7
2003/2004
2005/2006
1500
0
10
9
8
7
6
5
4
3
2
1
0
1961
8.9
7.2
2003/2004
2004/2005
2005/2006
2006/2007
2007/2008
2008/2009
AUDIT/EVALUATION
ANNUAL REPORTS AVAILABLE
[email protected]
CERYS FOLEY
SPECIALIST LEAD NURSE
RESPIRATORY SERVICES
ANEURIN BEVAN HEALTH BOARD
TORFAEN LOCALITY OFFICE
TORFAEN LOCALITY OFFICE