LAUSR

Introduction and objectives Local integrated respiratory services are well developed with a successful primary care enhanced service scheme for COPD and commissioned integrated respiratory consultant roles. However, hospital admission data suggests some patients still do not receive high value COPD interventions and pulmonary rehab completion rates in this group were low. Evolution of the GP Federation QIST (in affiliation with the Care closer to Home Integrated Networks ‘CHIN’) presented an opportunity to pilot a novel model of care to improve access to high-risk patients. It was proposed that proactively searching for such patients using primary and secondary care data with subsequent invite to an enhanced respiratory review would improve pulmonary rehab completion and admission rates. Methods Seven G.P practices formed a CHIN network during 2017. Four planning meetings were held between the consultant led community respiratory team and the QIST. Criteria for patient selection were: lack of annual review; ³4 courses of prednisolone and/or acute admission with AECOPD during the previous 12 months. Patients were invited for a 45 min review with a respiratory nurse specialist in a G.P practice. This replaced the need for usual COPD annual review. Results 96 patients were identified. 20 patients with an AECOPD admission were not on QOF registers but were included. 13 were already known to community respiratory services. 71 patients were offered either respiratory nurse clinic or home visit review. 10 patients were uncontactable, 15 declined, 9 did not attend. Initial contact by a clinician improved uptake. 36 patients were reviewed: 6 had their diagnosis modified, 20 required consultant MDT discussion, 9 were referred to pulmonary rehab, 3 were referred to stop smoking services and inhaled therapy was modified in 13 individuals. Conclusions The model increased delivery of high-value COPD care. Combining secondary and primary care data improved patient selection. The CHIN structure facilitated project management and strengthened relationships. The model has been modified to improve efficiency to include initial virtual review by the integrated respiratory consultant to guide management and triage onward referral. 12 further practice reviews are now underway and pulmonary rehab completion and admission data will be analysed.