Chronic obstructive pulmonary disease is the second most common cause of emergency admissions to hospital; one in eight acute emergency admissions is the result of an acute exacerbation of the condition.
COPD is also the fifth largest cause of readmission to hospital and accounts for the second highest number of total bed days in the UK. Forecasting by Sg2 shows that the NHS could save over £800m in COPD inpatient spend through more proactive care pathway management. This equates to a reduction in COPD inpatient activity of almost 50 per cent.
Today’s model of care is reactive, with a focus on treating acute exacerbations rather than preventing them. Proactive management of COPD could lead to fewer admissions from acute exacerbations.
Action plans empower patients to manage their own conditions and decrease the need for direct clinical supervision.
The first component of the proactive care pathway is to develop personalised action plans for all patients with COPD. The plan should include lifestyle goals for areas such as exercise and a personalised decision map for acute exacerbations. Details of who to contact and what medication to take at each stage of symptom deterioration should be listed, and the plan should be updated as part of a regular clinical review. Everyone involved in the care - family, carers, GPs, and so on - should have access to the action plan.
Improving patient education is the second component in the pathway, since patients who understand their condition and medications are more likely to make appropriate use of health services. All patients should receive teaching on the effect COPD has on the body, use of medications, lifestyle options, smoking cessation and management of exacerbations.
Some patients can be educated about self medication with corticosteroids and antibiotics. Education should be included across the continuum of care and be flexible to the needs and capabilities of each patient.
Patients who can readily access healthcare advice are less likely to seek emergency hospital care inappropriately. For this reason, a third component in the proactive care pathway is to establish easy and reliable patient access to suitable case managers. Ideally access to case managers will be around the clock. If this proves impossible, patients need to know who to contact and where to go when case managers are unavailable so that emergency services are not used inappropriately. Patients should be encouraged to use the advice service regularly so that they feel comfortable doing so. Relationships between patients and case managers can be fostered through regular phone calls and patient visits.
A proactive approach to the management of COPD requires a number of players, including the patient, case manager, discharge team, GP and education team.
The fourth component is to use technology to ensure seamless communication and transfer of information between everyone involved. Reliable and convenient communication by telephone, pager and email can be set up and remote patient monitoring can also be used. In an ideal situation, the patient’s medical records would be made universally available by using a web-based platform.
Case managers have a central role to play in the proactive approach to COPD management and therefore need to be identified early in the process of service redesign. All four components of the approach are essential for achieving the maximum impact, although local requirements will dictate where the emphasis is placed. It is also crucial that patients understand the system and are engaged in it.
Sustaining the COPD programme requires ongoing evaluation. Annual COPD patient attendances at A&E, hospital admissions, bed days and average length of stay for inpatient COPD care should all be measured. Success will see all of these metrics reduced.
The volume of COPD inpatient care may increase in the short term because of better awareness and diagnosis of the condition and improved patient understanding of when to seek emergency care. But in the long term, a proactive approach should improve management of acute exacerbations and reduce inpatient admissions.
Essentials for a proactive approach to COPD management
- Personalised action plans
- Patient education
- Patient access to healthcare advice
- Use of technology for communication and data transfer
Forecasting models from Sg2 show that taking a proactive approach to COPD management can reduce COPD inpatient activity by 46 per cent over the next 10 years, with savings of more than £800m to the NHS in inpatient COPD costs alone.
A saving of 32 to 46 per cent of present individual primary care trust spend on inpatient COPD can be expected by 2014. The Change Forecast online tool enables PCTs and strategic health authorities to calculate projected savings.
Also in the toolkit is a step by step approach to achieving the projected savings through a proactive care pathway. The Global Improvement Guide advocates a community-based programme that contains four components (see box right) and is co-ordinated by a case manager who could be a respiratory nurse or other trained clinician.