NCP Respiratory: NCP Clinics For Respiratory Integrated Care . - Hse.ie

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated careIn 2015 the British Thoracic Society (BTS) published updated guidelines anda structured framework for the assessment and follow up care of patientsrequiring home oxygen therapy. There is a strong recommendation in theguidelines that both LTOT and ambulatory oxygen therapy (AOT) should only beprescribed after detailed assessment by a respiratory specialist. Integrated OARreview clinics would support acute OAR clinics and provide primary care withan integrated model of care for the provision of specialist oxygen assessmentand follow up based on clinical standards set out by the ITS (2015). These clinicscomplement community pulmonary rehabilitation services and COPD Outreachservices by ensuring that patients have appropriate oxygen prescriptions anddevices.GPs are a key part of the early identification of hypoxaemia in patients withCOPD; this integrated pathway would facilitate GP access by direct referralsthrough a Consultant clinic in the hubs. OAR clinic support will be essentialin enabling rapid access to oxygen assessment for patients. Patients will haveaccess to standardised clinical assessment, appropriate and safely prescribedoxygen therapy and structured follow–up care providing them with a betterhealthcare experience.2.0 Chronic Disease Integrated ModelCommunity Healthcare Networks (CHN) will provide the foundation andorganisation structure through which integrated care for COPD will be providedlocally within the new Regional Health Areas (RHA). The CHN will support theGP- led chronic disease management framework and will be linked with an acutehospital at each site.Each CHN will cover an average population of 50,000 people. The networks arethe structures which will enable the multidisciplinary staff and teams to worktogether in a more coordinated and consistent way in a defined geographiclocal community based on the assessed needs of the local population providingintegrated care across hospital and community services.Three geographically adjoined CHNs will act as a point of access to specialistambulatory care teams (Hubs) within the community. The three networks willtotal approximately 150,000 population. The three networks will have direct linksto a local acute hospital service. The CHNs together with the Chronic DiseaseManagement Community Specialist Ambulatory Teams (Hubs) will providespecialist support to the GP in managing COPD & asthma in the community,thus ultimately preventing unnecessary hospital admissions, supporting earlydischarge and bringing care closer to home. The full spectrum of services thatshould be available to patients with chronic disease in any given network isoutlined in Figure 2.7

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated careThis pilot supports OAR clinics integrated and developed/ expanded in both theacute and community settings where appropriate. This integration will facilitateaccess for the service user in the setting most appropriate to their conditionand as close to home as possible. OAR clinics in the acute setting may be moresuitable for complex patients and first time assessments for LTOT; however localcollaboration between services in acute and the hubs will guide this process.Community OAR clinics may cater for less complex patients and reviewassessments e.g. yearly review. This decision will be made at a local levelunder the governance and direction of the respiratory consultant based onresources and the availability of staff with appropriate training (see competencyframework). In the event that only one location is possible due to resourcing,this clinic will provide services to their 3 mapped networks population. This willfacilitate clear pathways to provide a continuum of care for patients with COPDin keeping with the HSE COPD End to End Model of Care (2019).4Spe .ciaHos listpitaCare l3. AcuteSpAmb ecialistulatoryCareSpecialistAmbulatory HubCare in the CommunityHospitalCareIntegrated services also reflect the understanding that health and social careservices are performed by co productive partnerships and interdisciplinarycollaborations. Hospitals and community partners will need to work closelytogether to prevent avoidable hospital admissions and enable people to remainsafe and healthy in their own homes.2. CommunSAmb pecialis ityulattoryCare1. General Practice0. Livinchro g wellwnicdise ithaseLevelsof CareFigure1 COPD Model8COPD IntegratedService ModelEDOPDSPFT nttieInpCaareOPxDcases)plenissioclinicsdA mhceidan utreacova PD OCO(combehary Rona t teams etrymlumPispirocialSpe ics - s xygenclindoiew tion anveRcaeduttieng Panitawioreter d Reviess DleAsse Schedu PlanCare ClinicsualiageVirte TrhonpelTenntio ounteveCD Prtact itoringCOP ry CononverteMEtogppominuekSRaMnth/ealt agemehecelnTeervi-mafSlfeSes oExampl

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated careFigure 29

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care3.0 Acute & Community OAR teams3.1 Design of teamsThe design and implementation of an OAR clinic requires clear leadership,management, governance and accountability to ensure the quality and deliveryof a safe, patient focused service (see competency framework). The Modelof Care for Chronic Disease describes the delivery of services through anintegrated service model, with services being provided in the community butgoverned as an integrated service between hospital and community teams.The National Clinical Programme for Respiratory “End to End Model of Care forCOPD” combines these services under an integrated governance arrangementwith common standards, improved access for patients and achievement of goodclinical outcomes. All OAR clinics will be under the governance and direction ofthe respiratory consultant. Local pathways will be developed with the consultantto develop and progress the skills of the trained oxygen team over time. Thiswill include supporting prescribing rights for both nurses and physiotherapistsrelevant to the OAR clinic.3.2 StaffingThe OAR teams will consist of the respiratory consultant and suitably trainedrespiratory senior or clinical specialist physiotherapist and an Advanced NursePractitioner or Clinical Nurse Specialist.All staff will need to complete the competency described in the NCPCompetency framework for Respiratory Oxygen clinics and will be responsiblefor expanding clinical leadership and driving the vision of an integrated service.The team members will be autonomous practitioners in their speciality andwill have a close working relationship with the respiratory consultant and therespiratory medical team. They will be a point of contact for oxygen referrals andthe team will work across professional and organisational boundaries to expandand develop OAR clinics.The clinics will be staffed by respiratory physiotherapists and nurses from theambulatory care hubs for chronic disease and from acute settings with trainingspecific to the OAR clinic (see competency framework). This will include ABGsampling, training and competency. Staff will also develop local policies forthe clinic in conjunction with relevant stakeholders. This includes the locallaboratory, local aids and appliance officers and oxygen providers.10

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care3.3 GovernanceThe operational governance of each service lies with the Operational Lead /Network manager in the community and relevant head of discipline in acuteservices. The Operational Lead/Network Manager will coordinate the integrationof community healthcare services within the Network in response to the needsand requirements of the population. Professional governance will be provided toteam members from the associated managers for their individual discipline.4.0 PurposeThis document supports the rollout of the NCP pilot project and also providessupport and guidance to healthcare professionals to assist in setting up anddeveloping operational standards for OAR clinics and to ensure a continuum ofaudit and improvement in the quality of services.4.1 Aims of the service To provide an integrated oxygen assessment and review service. To improve access to oxygen services for patients closer to home. To provide a standardised and seamless patient journey betweenassessments and follow on care. To provide a safe and standardised approach to the provision of homeoxygen therapy to patients that is in line with national and internationalguidelines. Ensure equity of services for patients in each CHN and acute setting.4.2 Scope of the serviceThis guideline applies to all healthcare professionals involved in the NCP pilotproject including the referral process and provision of OAR clinics in the acutesetting and the chronic disease hubs.4.3 Patient populationThis pilot project is for adult patients 18 years with hypoxaemia and a confirmeddiagnosis of respiratory disease such as COPD or severe chronic Asthma.11

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care5.0 Referral pathway to OAR clinics5.1 Referral criteriaIn order for the referral to be accepted, patients must have inhaled therapies andtechniques optimised and meet the inclusion exclusion criteria set out below.Consideration of expansion of these inclusion criteria may be considered locallybased on the governance and direction of the Respiratory Consultant and thetraining and experience of specialist staff in ambulatory care hubs.Inclusion Criteria for Acute and CommunityExclusion Criteria Confirmed diagnosis of a chronic obstructive lungdisease by spirometry. Patients without a confirmed clinicaldiagnosis. A resting SpO2 of 92% breathing air or a fall inSpO2 of 4% to below 90% on exertion. Patients who are not pharmacologicallyoptimised. A resting SpO2 of 94% with evidence ofperipheral oedema, polycythaemia (haematocrit 55%) or pulmonary hypertension. Patients who are not in a stable phase oftheir disease. Optimal medical management and a period ofstability for a recommended 8 weeks prior to theassessment (exceptions for patients unable togain clinical stability, assessed on case-by-casebasis).Patients receiving oxygen therapy forconditions other than COPD and severechronic asthma (pathway to acute OARonly). Palliative patients who are normoxic i.e.SpO2 93% on air. Those patients with obstructive lung diseasewho currently receive oxygen therapy but do notrequire follow up in Secondary Care. Be in receipt of oxygen therapy without everhaving been formally or recently assessed (withinlast year).Pulse Oximetry is probably less reliable in dark-skinned patients. Pulse oximeters tend to over- read inthese patients, especially if the reading is below 94%. Consider ABG in dark skinned patients with oxygensaturations 93% or less where clinically appropriate to guide treatment. See ITS & BTS guidelines for furtherinformation.12

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care5.1.2 Pulmonary Rehabilitation Oxygen requirementPatients needing rehabilitation support after discharge from the acute hospitalor recovering at home are referred into an active recovery pathway. This serviceis collaborative with interdisciplinary referral and delivered by the pulmonaryrehabilitation team or the relevant team member at home. The COPD Outreachteam and the pulmonary rehabilitation team may refer or liaise with the OARclinic if required for assessment for oxygen requirements identified duringassessment or over the course of rehabilitation.5.2 Referral pathwayPatients meeting the inclusion/exclusion criteria can be referred by theConsultant, other Physiotherapists or nursing staff from both Primary andSecondary Care and referred via a standardised referral form to the appropriatelocation via e-referral.Following initial assessment, those patients who require LTOT and/or AOT maybe referred to Secondary Care if complex needs are identified during assessmentsuch as a potential requirement for non-invasive ventilation or sleep therapies.This cohort will be handed back to the Primary Care team for follow up oncestabilised and/or jointly managed by the integrated services.Referrals for patients who may require oxygen assessment but do not haveCOPD (e.g. Heart Failure, Pulmonary Fibrosis, cluster headaches) may be sent toSecondary Care teams for formal oxygen assessment.13

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated careReferrals from GeneralPractitioners to Consultant ClinicsReferrals from SpecialistRespiratory Hospital TeamsReferrals from Ambulatory CareChronic Disease HubOxygen Assessment &Review (OAR) clinicOAR team screen referral forinclusionYesNoPatient suitable, but had recentexacerbation. Appointmentdelayed until clinically stableComplex case due to comorbidconditions such as Type 2Respiratory Failure, InterstitialLung Disease or Heart FailurePatient prioritised and placed onwaiting listCase discussed with ConsultantPatient referral forwarded toSecondary Care Teams if in place(Can include detail on time frames)Patient attends OAR clinicoutcome of which is reported backto primary referrer and GPFigure 3. Referral Pathway to Oxygen Assessment & Review clinics14

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care6.0 Oxygen assessmentAll oxygen assessments are carried out in accordance with national andinternational guidelines and standards. The sample oxygen assessment pathwayin figure 4 can be used as a guide for this pilot project and adapted locally. Theprotocol for oxygen titration and LTOT prescribing is advised to be utilised atinitial and annual reviews and following national and international guidance(Hardinge et al, 2015).15

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated careReferral SourceInitial OAR assessmentin Primary CareRespiratory Consultant clinicSecondary CareCOPD OutreachPulmonary RehabilitationConditions other thanCOPD or Asthma(adults) should bereferred to SecondaryCare OAR clinics ifavailable 8 weeks post exacerbation Earlier if frequent exacerbations 8 weeks after discharge fromsecondary care where newLTOT/AOT was commencedIs hypoxaemia/desaturationconfirmed?NoYesReassess in 3weeksRefer back to GP/Specialist teamIf borderline, reassessin 3 months. Considerreferral to pulmonaryrehabilitation ifappropriateIs hypoxaemiaor desaturationconfirmed?NoRefer back to GP/Specialist teamYesLTOT and AOTas indicatedConsider referralto pulmonaryrehabilitation ifappropriateFigure 4: Sample Oxygen assessment pathway16YesLTOT follow up:Annual OAR assessmentAOT follow up:8 week OAR assessmentAnnual OAR assessmentWith additionalhypercapnia:Refer to OAR clinicin secondary care forfurther assessment ifavailable

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care6.1 First assessment6.1.1 F or details on assessment and suitable quality of life scores and assessmenttools, overnight oximetry and AOT see ITS/BTS guidelines.6.1.2 Staff will discuss the rational for oxygen therapy with the patient. This is aminimum should cover the prescribed requirements (both LTOT and AOT)and safety aspects of oxygen therapy in the home, followed by appropriatepatient information leaflets.6.1.3 I f the patient is a current smoker or members of their family are currentsmokers, brief smoking cessation advice is provided. Local hub policy andagreement with the governing Consultant Respiratory Physician will direct ifpatients who are current smokers should be commenced on LTOT/AOT. Thiswill be decided on a case-by-case basis with frequent review.6.1.4 The patient and other residents in the home need to be strongly counselledon the risk of fire and personal injury associated with smoking or nakedflames and the use of home oxygen therapy. It should be made clear thatno amount of smoking in the home where oxygen is supplied is acceptable.Advice should be provided on the need for a working smoke alarms, fireblankets and/or extinguishers.6.1.5 For information on follow up visits please see ITS guidelines. Local policyand patient complexity will define requirement for subsequent visits to theclinic in the acute or community setting.6.2 LTOT: annual review6.2.1 A full review of all patients on oxygen therapy is carried out annually fromthe date of the first appointment with the service.6.2.2 A ssessments are performed as per initial assessments in accordance withinternational and national guidelines and standards.6.2.3 Existing oxygen users will have their oxygen prescription checked by theOAR team against their actual usage (information to be requested throughoxygen suppliers) and amended as clinically appropriate to their needs.6.2.4 P atients identified as having additional health care needs will, withtheir consent, be referred or signposted as required to the appropriatecommunity services and managed in partnership between the OAR teamand other services e.g. Public Health Nurse, Palliative Care, PulmonaryRehabilitation, HSCPs, disease specific support groups, Mental Healthservices, GP etc.6.2.5 S ervice user feedback will be sought annually by OAR team via a PatientExperience Questionnaire.17

NCP Respiratory: An operational guidance document for a National Clinical ProgrammeRespiratory pilot project to support and set up Oxygen Assessment and Review (OAR)Clinics for Respiratory Integrated care6.2.6 E xisting patients on oxygen who no longer meet the clinical requirementsfor oxygen therapy will work in partnership with the OAR team to develop apersonalised care plan to wean off their oxygen prior to it being withdrawn(in as many cases as possible).6.3 Ambulatory Oxygen Therapy (AOT)assessment and follow-up.6.3.1 Ambulatory oxygen assessments are carried out in accordance with nationaland international guidelines and standards.6.3.2 P atients who commence AOT without LTOT should receive a follow up OARclinic assessment 8 weeks after commencing the therapy and annuallythereafter.7.0 Discharge Criteria7.1 Patients should be discharged from the OAR service if: They do not attend or decline 3 offers of an appointment. Oxygen therapy is no longer deemed to be required after a completeassessment. Oxygen therapy is withdrawn and sufficient monitoring time has beencompleted.7.1.1 Discontinuation of home oxygen therapy can be complex and may requireseveral reviews or a weaning/reduction programme. It is particularlydifficult where equipment has been in place for some time regardless ofuse. The process can be stressful for patients and their families so shouldbe approached sensitively. If they are using oxygen for breathlessnessalternative supports for this should be considered, such as pulmonaryrehabilitation, palliative care o

Clinics for Respiratory Integrated care 5 1.0 Background and context The purpose of this document is to support a pilot project on setting up Respiratory Integrated OAR clinics by the NCP Respiratory. This project will be reviewed in 12 months and is planned to be a stepping stone towards further development in the integrated OAR clinics in the .