Improving home oxygen: testing the case for change
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This document discusses several NHS projects aimed at improving home oxygen services. It describes how the projects focused on reviewing patient lists, rationalizing unnecessary oxygen usage, and improving coordination of care. Through these efforts, the projects generated an estimated total of £640,000 in prescribing cost efficiencies. The document provides details of the various projects' approaches, which involved defining patient care pathways, identifying variations in care, and testing solutions through a quality improvement framework.
Improving home oxygen: testing the case for change
- 1. NHS CANCER NHS Improvement Lung DIAGNOSTICS HEART LUNG STROKE NHS Improvement - Lung: National Improvement Projects Improving Home Oxygen: Testing the Case for Change
- 3. CONTENTS 3 NHS Improvement - Lung National Improvement Projects Improving Home Oxygen: Testing the Case for Change Contents Introduction 4 Case studies • Wirral University Hospital NHS Foundation Trust and NHS Wirral 10 Wirral Integrated Community Oxygen Service • NHS Hull and the City Health Care Partnership 12 Home Oxygen Service Improvement Project • Royal Free Hospital NHS Trust, NHS Waltham Forest & North East 14 London, North Central London and Essex Health Innovation Education Cluster (NECLES HIEC) The feasibility and impact of withdrawal of Short Burst Oxygen Therapy (SBOT) • NHS Nottinghamshire County Community COPD Team, 16 Sherwood Forest Hospitals NHS Foundation Trust and County Health Partnership Home oxygen – improving quality of care • NHS Sheffield and Sheffield Teaching Hospitals 17 NHS Foundation Trust Home oxygen service improvement project • NHS Blackpool and Blackpool Teaching Hospitals 18 NHS Foundation Trust Improving oxygen services and the prescribing of oxygen across NHS Blackpool • NHS South Staffordshire 20 Improving home oxygen services through pathway redesign • Milton Keynes PCT Community Services and Milton Keynes 21 Hospital NHS Foundation Trust Sustaining the efficiency and effectiveness of the Milton Keynes Home Oxygen Service – Assessment and Review (HOS-AR) Acknowledgements 22
- 4. 4 INTRODUCTION Introduction Case for change: the current Reducing variation in service The first year of project work position for home oxygen provision can help tackle health focussed on continuous patient list services in England inequalities and ensure consistency review and the systematic in the safety and efficacy of utilisation of oxygen usage supplier Home oxygen therapy is provided services. These are among the data to support clinical decision to about 85,000 people in goals of The Outcomes Strategy making around therapy alteration England, costing approximately for COPD and Asthma in England (or withdrawal) and to drive more £110 million a year1. Home as outlined in objective 2 and coordinated prescribing and oxygen service – assessment and objective 5 of the six shared improved multi-disciplinary care. review (HOS-AR) is variable as objectives set out in the strategy2. patients in many Primary Care The project work was undertaken Trusts (PCTs) do not receive a against the backdrop of the quality assured clinical assessment national re-procurement of oxygen and a review of their ongoing need The aim of the Improving supply contracts, which was for long term home oxygen. Home Oxygen just gathering pace. The workstream is to ensure re-procurement together with the The variation in provision of HOS- that patients with a NHS Quality, Innovation, AR increases the potential for poor clinical need for home Productivity and Prevention agenda quality care and waste and it has oxygen receive gave additional context to the been estimated that 24% to 43% appropriate, safe and work and provided an opportunity of home oxygen prescribed in cost effective therapy on for clinical teams to engage local England is not used or provides no a sustainable basis as a commissioners, finance and clinical benefit1. result of an efficient care medicines management in new pathway providing and different thinking about Home Gross savings of up to 40% - specialist assessment and oxygen service –assessment and equivalent nationally to £45 million ongoing clinical review. review. a year or £300,000 per PCT can potentially be achieved through This publication is aimed at the establishment of home oxygen healthcare professionals, services, oxygen register review NHS Improvement - Lung worked commissioners and other key and formal clinical assessment1. with clinical teams across England stakeholders involved in respiratory supporting them in identifying, health services. It draws together testing and implementing the the evidence and learning from the changes needed to achieve good work undertaken by the national practice in HOS-AR and seeking to COPD projects constituting the understand the key components initial 12 months of the Improving that have the greatest impact on Home Oxygen Services the patient pathway. workstream. Home Oxygen Service – Assessment and Review – Good Practice Guide, NHS Primary Care Commissioning (2011) 1 An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, Department of Health, July 2011 2
- 5. INTRODUCTION 5 Improvement approach However, focus was also given to The project sites adopted a improving the patients experience systematic approach to quality NHS Improvement – Lung invited and outcomes, and to the removal improvement to ensure that any NHS organisations to work in of duplication and waste from the changes implemented were partnership on projects dedicated to pathway and from specific processes thoroughly tested and measured. improving the COPD patient through different ways of working Prior to commencing the work the pathway and to help address the and service redesign. project sites were required to geographical variation in care that establish their service baseline patients receive. Projects plans were Through patient list cleansing, through analysis of local data and to submitted from a number of sites rationalising individual patient’s understand the variation in services. including acute trusts, primary care oxygen usage (in terms of flow rate, trusts (PCTs) and community supply duration and supply devices) Upon the establishment of individual organisations. in line with their clinical need, project teams, a period of ‘diagnosis’ supported withdrawal of followed in order to allow teams to The primary aims of the project inappropriate therapy and healthcare understand the patient pathway and work were to provider education to avoid dispel a number of assumptions inappropriate prescribing, 9 out of about the processes, its challenges • Locally define and implement the the 12 oxygen workstream project and the solutions. Potential solutions patient’s home oxygen care teams delivered collective prescribing were tested using the model for pathway in alignment with the cost efficiencies totalling improvement and Plan-Do-Study-Act standards enshrined within the approximately £640,000. (PDSA) cycles with ongoing Good Practice Guide national measurement to evaluate the impact publication During this ‘testing’ phase of the of the interventions and refine • Identify and reduce variation in the national programme the project where appropriate. delivery of care teams have explored the reality of • Test the components of care that making local service improvements led to an effective HOS-AR model by taking stock of current practice • Identify the success principles that and understanding the other organisations and teams implementation process necessary could learn from and adopt for the delivery of optimal patient • Inform future ‘prototyping’ work. care in a challenging environment.
- 6. 6 INTRODUCTION Common challenges and solutions Whilst each project site has worked on a different part of the home oxygen pathway, a number of key themes have emerged Clinical teams at all sites have been across all oxygen project sites which have enabled the focussed on specific aims which development of six top tips for improving home oxygen have included: services: • Develop accurate registers of 1. Provide oxygen assessment and review staff with access to patients in receipt of home oxygen supplier data and support in its effective use therapy 2. Use clinical and supplier data systematically to support • Utilise the home oxygen service appropriate prescribing, clinical assessment with ongoing data around initiating prescriber, review and tight cost control oxygen consumption, flow rates, 3. Integrate your oxygen service within the wider respiratory patient concordance and therapy pathway and coordinate activities with non-respiratory modality more effectively and in specialties combination with clinical data 4. Promote the message that ‘home oxygen is a treatment for about individual patients chronic hypoxaemia and NOT a treatment for • Ensuring all existing and future breathlessness’ patients in receipt of home oxygen 5. Work collaboratively to formalise policies and procedures receive clinical assessment and around the safe use of home oxygen ongoing review in line with best 6. Establish ongoing and effective communication between practice the oxygen team, primary and secondary care to ensure • Improve care for non respiratory appropriate prescribing, appropriate referrals and patients in receipt of oxygen by continuous education for patients and professionals. better collaborative working with non-respiratory specialists • Rationalise prescribing of home oxygen to reflects the clinical need of the local population • Control home oxygen therapy costs • Develop and implement effective risk assessment and health and safety procedures • Achieve greater integration of assessment and review services within wider care pathway.
- 7. INTRODUCTION 7 Project outcomes: Emerging success principles and project learning NHS Improvement - Lung provides structured support to project teams enabling them to solve problems by addressing root causes and by undertaking a systematic approach to service improvement. Teams across the different workstreams of the national programme worked through a number of different challenges in order to achieve their project aims. However some common principles have emerged as critical success factors in all national COPD projects: 1. Defining and gaining a good understanding of the whole pathway of care - having a complete understanding of the care pathway supported by robust data to demonstrate the effectiveness of current processes, quantifying performance and variation is essential when embarking on improvement work. This allowed organisations to identify priorities for change and also to benchmark themselves with others locally and nationally. Home oxygen project teams used supplier and clinical data on patients’ condition, therapy consumption and compliance together with an improved understanding of the sources of prescribing and sources of referral to local services in order to rationalise therapy in alignment with clinical need. 2. Taking an integrated approach to service development - issues and challenges viewed in isolation without due consideration to the whole patient pathway were less likely to lead to sustainable improvements in care provision. Oxygen services need to be viewed within the wider respiratory care pathway to maximise the opportunities for integrating with services such pulmonary rehabilitation and to ensure patients receive optimal and coordinated management of their overall respiratory condition. 3. Clinical collaboration across the care pathway - effective working relied on the commitment of teams in primary, secondary and community care to improve communication across the patient pathway. Integrated working helped to build positive relationships with health care professionals, departments and organisations, and improve the critical interface between these organisations. Home oxygen teams often had to consider patients with a range of conditions not just COPD and as such had to collaborate with non-respiratory specialists in order to ensure coordinated management of patients requiring oxygen for neurological and cardiac conditions as well as patients requiring oxygen for palliative care.
- 8. 8 INTRODUCTION Next action steps for NHS teams seeking to improve home oxygen 4. Clinicians and managers reviewing data together - access to services and effective use of data through collaboration between clinical and managerial staff enabled the project teams to better understand the The learning from this first year of patient pathway and demonstrate the impact of any change. The project work indicates that other routine collection and review of data was important in implementing NHS teams considering improving sustainable improvements and understanding outcomes of any service home oxygen services should focus improvements. activity in three areas: Oxygen teams worked with non-clinical colleagues to understand sources of inappropriate prescribing and inappropriate referrals for 1. Review oxygen usage data clinical assessment. This enabled targeted education to be and improve data undertaken within both the community and within hospital settings management – ensure the accompanied by ongoing data review to assess changes in healthcare clinical team has routine access to professional behaviour. supplier data and is collaborating with non-clinical colleagues 5. Identifying the key levers and drivers in the system - by around patient list cleansing, integrating local and national priorities into the work such as Quality, identifying candidates for therapy Innovation, Productivity and Prevention (QIPP) project teams raised the rationalisation. The clinical team profile and priority of the project work with decision makers and should provide clinical insight to helped to achieve improved engagement from senior management managers and administrators teams. undertaking monthly invoice reconciliation and collaborate in Both the QIPP agenda and the national re-procurement of oxygen the review of patient compliance supply contracts provided an opportunity for clinical teams to engage using the quarterly concordance other clinical and non-clinical stakeholders in a new dialogue about reports. issues such as home oxygen therapy usage, reporting arrangements, 2. Establish clinical assessment HOS-AR service specification and its integration within the wider care and ongoing review – identify pathways, treatment goals, fire safety, risk assessment and the all patients currently in receipt of coordination of community and hospital care. home oxygen in order to address any assessment/review backlog, 6. Value for money - there was a need to identify and understand utilise local booking systems to the gaps, duplication and waste in the patient pathway in order to capture referrals for initial make best use of available resources. It was essential to work and assessment and to establish the communicate with colleagues, commissioners and other stakeholders review cycle. Undertake in service provision in order to maximise these resources and to ensure appropriate therapy a consistent and co-ordinated approach to care. modifications, the supported withdrawal of inappropriate Commissioning, finance and medicines management colleagues therapy, patient safety risk worked closely with home oxygen clinical specialists to identify assessment and ongoing patient prescribing anomalies, to address waste, to improve the clinical education. governance in respect of the safe use of home oxygen and to manage the performance of the oxygen suppliers.
- 9. INTRODUCTION 9 3. Service integration and • Home oxygen services- The testing phase work sustainability – undertake assessment and review demonstrated that the potential cost process mapping with the resource hub - an online toolkit efficiencies identified by the multidisciplinary team to which will identify key data Department of Health and understand the current home measures and clearly articulate the attributable to therapy oxygen patient pathway for the success principles for sustainable rationalisation through home oxygen medical conditions being implementation of HOS-AR. This service –assessment and review can managed. This should be used resource will provide case studies, be realised in practice. It is together with detailed local examples of protocols, procedures anticipated that the prototype phase contextual data about prescribing, and pathways together with Top- of work will further demonstrate the usage, costs, home oxygen service tips and ‘next steps’ action sheets. importance of assessment and activity, demand and capacity in • Safe use of oxygen support review in the maintenance of safe, order to ensure the service package - highlighting issues of high quality, equitable and cost specification supports the patient safety and risk efficient home oxygen services. development of a cost-effective management for the local pathway and aligns with local development of patient education commissioning considerations. programmes and also the strengthening of local clinical Future ‘prototyping’ work governance arrangements through a partnership between patients, In the forthcoming year of project local NHS organisations, oxygen work sites will be building on the suppliers and fire services. learning from the ‘testing’ phase of • Spread Framework for Home work. Sites will be refining the Oxygen Service - assessment components attributed to the and review – guidance to assist emerging care models and success clinical leads, home oxygen service Phil Duncan principles that demonstrated the leads, clinical commissioning Director, NHS Improvement - greatest impact on the patient Lung groups and clinical networks in pathway during the past year. their collaborative effort to drive the regional implementation of The prototyping work will define the HOS-AR and the widespread efficient and high quality care model adoption of good practice in that reflects best practice, but also home oxygen services. demonstrates examples of practical approaches towards sustainable implementation. This will include work that focuses on the delivery of a number of products: Ore Okosi National Improvement Lead, NHS Improvement – Lung
- 10. 10 CASE STUDIES Wirral University Hospital NHS Foundation Trust and NHS Wirral Wirral Integrated Community Oxygen Service What was the problem? The challenge for this community based Graph title required?? (but integrated with secondary care) 45 New team of nurses, physiotherapists and 40 New patients prescribed administrative staff providing COPD, by specialists Pulmonary Rehabilitation and Oxygen 35 Number of Patients New patients prescribed services was to work more effectively 30 by non specialists with the wider multidisciplinary team to 25 New patients prescribed by us - palliative manage patients on oxygen therapy who 20 Linear (new patients prescribed have a wide range of health problems 15 by non specialists) (not just COPD). In addition, the team Linear (new patients prescribed 10 by us - palliative) sought to maintain or even increase the 5 Linear (new patients prescribed cost efficiencies and improvements in by specialists) patient care it had achieved through 0 Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Linear (new) patient review and the use of oxygen Month budget and concordance data when the service was first established. What was the aim? By the end of July 2011, all existing adult What has been achieved? What are the key learning points? patients registered with a Wirral GP and • All existing patients on home oxygen • It is important to establish prescribed oxygen will have had a therapy have been reviewed communication networks with local structured assessment. New patients will • Maintenance of tight cost control with primary and secondary care be formally assessed before oxygen is continued reduction in non specialist stakeholders. By attending (or prescribed and all patients will have a oxygen prescribing presenting at) local professional scheduled review programme. Patients • Acceptance of the service by other forums opportunities to build trust and who are prescribed oxygen will have the community based teams and other educate other healthcare professionals most clinically and cost effective non-respiratory specialist teams can be realised. The education process treatment. • Development of a pathway for is reinforced through individual supported withdrawal of short burst discussion of non-specialist • All adult patients on Wirral should oxygen therapy (SBOT) prescriptions and by giving feed back have a structured assessment prior to • Formalisation of (safety) risk to referrers post patient assessment commencing home oxygen in line with assessment with adoption of • Using a model that integrates oxygen national guidance. This excludes documented procedures and assessment and review with COPD and patients for whom oxygen is palliative escalation process PR services and is supported by for terminal illness • Positive feedback from patients via an secondary care has contributed to the • Oxygen will only be prescribed if external patient evaluation of the success of this community based clinically indicated service service. Control of the prescribing of • All adult patients on oxygen should be • Development of a shared care oxygen taking place within the acute reviewed at least every six months to treatment pathway with heart trust via hospital based respiratory ensure their prescription remains specialist nurses has reduced their nurses reduces inappropriately appropriate for their needs referrals for SBOT. prescribed oxygen and improves • Unnecessary oxygen prescribing should communication about patients who be eliminated need further assessment and review • An on-going education programme for health professionals about the indications, prescribing and use of oxygen will be established.
- 11. CASE STUDIES 11 • Autonomy in setting up and Contact developing the service coupled with Denise Williams strong leadership and clinical and Nurse Consultant/ COPD and managerial support is vital Oxygen Service Manager • The importance of obtaining and maintaining accurate data about Tel: 0151 514 2245 or ext. 3243 patients, review cycles and cost Email: denise.williams12@nhs.net analysis should not be underestimated, neither should the time and skill taken to do this consistently • Consistent, high quality assessment and review by expert practitioners is vital in gaining and maintaining the trust of the patient, carers and clinical colleagues. Cost effective prescribing should follow on from this and not be the prime motivation • Developing positive relationships with other specialist teams and clinical colleagues is vital to be accepted as part of the patient’s clinical management team. This can only be achieved by sustained effort and networking.
- 12. 12 CASE STUDIES NHS Hull and the City Health Care Partnership Home oxygen service improvement project What was the problem? Final procurement of local Home Oxygen Service – Assessment and Review (HOS- AR) coincided with the start of the NHS Improvement-Lung project. The project had a split focus, one area being the successful commencement of HOS-AR with the associated challenges of establishing a new referral pathway, accessing, interpreting and using data and also the clinical review of 876 existing patients currently receiving home oxygen. The second area of focus was to establish robust procedures around risk, health and safety and smoking as this had been identified as a local priority. Picture features Home Oxygen Clinical Team only - the full project group comprised What was the aim? PCT commissioners, smoking cessation, patients, oxygen supplier and the Fire Brigade To contribute to a reduction in unscheduled hospital admissions and optimise chronic obstructive pulmonary disease (COPD) patient care through the What has been achieved? • Prior to the service commencing the delivery of appropriate and cost-effective • Patients at risk have been identified by number of patients in Hull in receipt of oxygen therapy to COPD patients the HOS-AR team and joint visits have oxygen was 876, the current caseload, identified as being in clinical need been undertaken with the Fire Brigade as of 3rd October 2011, is 579 determined through assessment by together with the development of a • Home oxygen monthly invoices have trained healthcare professionals. joint risk assessment pathway and reduced by £15k since the service arrangements for future joint training commenced a reduction in annual • Remove inappropriate oxygen between both teams forecast spend of £0.204m provision, ensuring correct equipment • A policy for the delivery of HOS-AR has • Patient experience as obtained using and therapy is delivered to new and been developed and approved by City the Long Term Conditions LTC6 existing patients on oxygen Health Care Partnership with regular questionnaire was overwhelming • Reduce unnecessary costs of oxygen education for local primary, community positive and scored highly in respect of and equipment and secondary care (on best practice, patient involvement in decision- • Risk assess patients/carers prior to and referral criteria and optimising making, information provision, joined- during their use of oxygen therapy treatment) built into the team’s service up care and team support. • Work with the local fire brigade to specification produce and develop a workable local • A draft health and safety oxygen use policy on smoking and oxygen policy has been developed and it is provision hoped that all stakeholders will be • Educate patients on health and safety signing up to its use shortly issues surrounding smoking and oxygen therapy • Develop a written (signed) contract During the period of April 2010 - September 2011: between patient and health care New referrals into the service for patients not in receipt of oxygen 341 professional (HCP) with clauses to Assessments and or follow ups undertaken 1630 remove provision on grounds of health Number of those new referrals which were inappropriate 109 and safety or no clinical need/benefit. Patients were discharged from the service, no longer requiring oxygen 168 Removals of modalities 435 Commencements on oxygen modalities 322 Increases in oxygen flow rates 234
- 13. CASE STUDIES 13 What are the key learning points? • Locally, just as is the case nationally, Contact • Using cost and usage data from the there is no clinical consensus on the Toni Yel oxygen supplier is the smartest way to issue of therapy withdrawal in hypoxic Business Development Manager determine a starting point for patients who continue to smoke. assessing and reviewing patients. A However, the team work proactively to Mobile: 07530 719 852 template is being developed to support manage and minimise the risks to Email: toni.yel1@chcphull.nhs.uk integration of clinical system reporting patients and their surroundings with oxygen reporting systems. Quick through education, working with financial wins came from the stakeholders and by involving the administration team working through COPD Smoking Cessation Specialists the invoices and identifying and the Fire Brigade in care pathway discrepancies and reporting this back development. This has been really to the oxygen supplier successful and has led to a number of • A lot of time was spent gaining an reported ‘quitters’ among existing understanding of the data (with the oxygen patients identified as continued suppliers help) and what it meant smokers before the team were able to analyse • Having the commissioners leading this the information and use it proactively multidisciplinary project has driven the • Working with the Fire Brigade has work, but the project would have had helped tackle the challenges a stronger voice in the wider health experienced by the team in educating community if the project team had a patients and carers of the risks around consultant or GP among its health and safety and on dangers of membership. smoking to themselves and others, making such discussions more impactful
- 14. 14 CASE STUDIES Royal Free Hospital NHS Trust, NHS Waltham Forest & North East London, North Central London and Essex Health Innovation Education Cluster The feasibility and impact of withdrawal of Short Burst Oxygen Therapy (SBOT) What was the problem? The results of 19 patients in terms of What are the key learning points? There is considerable evidence from HAD, SGRQ, FEV1 (morbidity) and The issues relating to withdrawal of home oxygen service data and related oxygen SaO2 at assessment on first visit SBOT are highly complex and multi- surveys that the use of short burst are presented in the oxygen workstream factorial. They relate not to sub-optimal oxygen (SBOT) or intermittent oxygen at emerging learning publication management, but rather to the fact that home, for the relief of breathlessness in www.improvement.nhs.uk/lung this subgroup of patients have severe patients without chronic hypoxemia, is COPD, are unwell, are maintained at still being provided, despite considerable In the second PCT, the project team home and are too sick to consider published data that it is not effective and encountered considerable difficulty in removal of oxygen. The majority of is therefore costly to the NHS. This accessing oxygen usage data. The patients in this study had SBOT project was undertaken to address the project team developed a questionnaire prescribed for over 12 months (often issue of the prescription of short burst exploring the issue of oxygen data access following an exacerbation) which had oxygen (SBOT) for patients with chronic and it’s usefulness in managing care and also led to some psychological obstructive pulmonary disease (COPD). circulated it to 17 teams within the NHS dependence over time. However, the Improvement-Lung national programme. project duration spanned an excessively What was the aim? The 12 completed questionnaires cold period with a high incidence of To review all COPD SBOT prescriptions, indicated: acute exacerbations where patients of more than 3 months, in two PCT genuinely needed their SBOT and which areas, in order to reduce SBOT • Variation in ease of access to data was felt to be justified by their clinician. prescription by 75% over the course of across the respondents one year (July 2010 to July 2011). This • Clinicians do not have access to the The following points have become clear target figure was deliberately aimed high full range of data during the project: as most SBOT patients (with the • Respondents all doing something exclusion of palliative prescriptions) have slightly different depending on their • Communication between the no clinical indication for SBOT. location community and hospital on discharge • Access via commissioners and PCT but needs improving to ensure seamless What has been achieved? not available to secondary care care of home oxygen patients Twenty-five patients on SBOT in the • Accuracy of data a problem • Patients were discharged with no borough of Waltham Forest with a • Current and accurate tariffs not always information about the use of oxygen primary diagnosis of COPD were available so hard to control and once at home and no support identified. Appointments were sent and manage expenditure regarding their oxygen therapy patients, who agreed to participate in • Issues over data protection resulting in • Patients commenced on SBOT for an the project, visited in their homes: challenges around wider access to data. exacerbation need reviewing at six weeks for assessment, education and support with a view to removal to avoid psychological dependence Results of Oct to Jan to • Whilst there is an assumption that home visits Dec 2010 Jun 2011 patients on SBOT have been given it erroneously, this study has SBOT successfully withdrawn 2 demonstrated that in the majority of Exacerbating at time of assessment 9 these cases, this has not been the case • There needs to be clarity about the Withdrawn from study project 2 correct prescription of LTOT, given the SBOT left in place on compassionate grounds 2 complexity of removal of SBOT Refused assessment 1 SBOT replaced by LTOT or Ambulatory Oxygen 1 Admitted to hospital 1 Total 18 7
- 15. CASE STUDIES 15 • Patients who are prescribed SBOT may not have been seen by a clinical specialist in oxygen therapy and may not have been told how long the prescribed oxygen should be used • Patients who are prescribed oxygen in nursing homes need to be reviewed and require clinical specialist support in their management, the management of nursing homes need to be informed that patients require regular assessment and that appropriate and cost effective arrangements can be put in place for emergency oxygen supplies. Contact Christine Mikelsons Consultant Respiratory Physiotherapist (Royal Free) Tel: 0207 794 0500 ext 34068 or bleep 1041 Email: christine.mikelsons@nhs.net Anne Crawford Respiratory Services Team Lead / Respiratory Nurse Specialist (Waltham Forest) Tel: 0208 430 8255 Email: anne.crawford@wf-pct.nhs.uk
- 16. 16 CASE STUDIES NHS Nottinghamshire County Community COPD Team, Sherwood Forest Hospitals NHS Foundation Trust and County Health Partnership Home oxygen – improving quality of care • Develop the systems and protocols to introduce GP direct access and to target hospital discharge oxygen • Re-categorise therapy modality or remove oxygen therapy for a large number of patients and consequently recover a projected £98,000 in annual costs attributable to inappropriate prescribing. What are the key learning points? • Integration of home oxygen services with pulmonary rehabilitation provides a seamless service for patients. It increases key worker understanding of both therapies and it also improves service efficiency. In addition, both What was the problem? Objectives: patient knowledge and experience is The community COPD team, in • Introduce GP direct access to the improved which leads to informed collaboration with the local respiratory oxygen assessment service patient choices and more appropriate function department established a • Quantify the work that would be prescribing community based oxygen assessment associated with retrospective • Pulmonary rehabilitation is the ideal service, co-located with an existing assessment (for patients with oxygen platform to trial ambulatory oxygen consultant led COPD clinic and a and no history of assessment) therapy pulmonary rehabilitation service, with • Develop a strategy for the • Patient review provides the ideal assessments being provided across two identification and assessment of opportunity to re-categorise the sites. patients discharged with oxygen oxygen supply according to changing following a hospital admission clinical and social needs The service proved successful and highly • Improve oxygen prescribing ensuring • Liaison with data analysts is important regarded by patients but was not utilised therapy matched clinical need and in order to make effective use of by all prescribers of oxygen, resulting in a actual usage, and also to reduce available oxygen usage data significant proportion of patients supply costs. • Access to monthly oxygen supply receiving home oxygen without clinical invoices is important to track what is assessment. The service recommended What has been achieved? happening to the oxygen supply to the PCT and to PBCs that prescribing Although audit and review of oxygen • Encouraging dialogue between the without assessment should be barred but patient registers and oxygen usage data home oxygen service and primary care the advice was rejected thus alternative suggested the need for a significant together with improved accessibility to options to address the shortfall of increase in staff and staff availability (in specialist HOS-AR team advice was assessments needed to be developed. order to undertake retrospective important in ensuring improved assessments), through service re-design oxygen prescribing. What was the aim? the project team were able to: The project aimed to increase the Contact proportion of patients undergoing • Increase the number of assessment Dr Sue Revill oxygen assessment and regular review in sessions Clinical Scientist COPD Services order to improve both patient • Identify areas where they could management and cost containment by integrate with other community teams Tel: 01623 785407 introducing a ‘direct access’ pathway for in order to streamline and increase Email: sue.revill@sfh-tr.nhs.uk general practice, community nursing and service capacity other medical prescribers, thereby • Improve integration within the COPD supporting areas with high rates of community team i.e. integrating the oxygen prescription (i.e. hospital services of oxygen assessment and discharge and general practice). pulmonary rehabilitation
- 17. CASE STUDIES 17 NHS Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust Home oxygen service improvement project What was the problem? NHS Sheffield as part of their Achieving Balanced Health Strategy (2010) identified that they had the highest projected forecast spend on home oxygen therapy. There was no local requirement for patients to have an oxygen assessment in advance of therapy being ordered /prescribed and patient’s ongoing need for oxygen therapy was not always reviewed. What was the aim? By July 2012, all NHS Sheffield chronic obstructive pulmonary disease (COPD) patients newly prescribed home oxygen have had an initial quality assured assessment and all COPD patients with home oxygen are systematically reviewed in line with British Thoracic Society/NICE guidelines resulting in the correct therapy (detailed on home oxygen order • Improved communication and • Garner wider organisation support – forms and equipment) and leading to understanding between PCT the engagement of Clinical improvements in patient quality of life, commissioners and service providers. Commission Group (CCG) enabled the increased life expectancy, reduced • Raised the profile and importance of profile of home oxygen therapy (unscheduled) admissions and robust pulse oximetry among local GP's patients and service issues to be raised oxygen cost control. • Improved use of data from oxygen within the CCG supplier • Undertake analysis of service demand What has been achieved? • Reduction of between £120K to and capacity with service provider staff The cost saving potential and £150K in estimated annual oxygen to inform the service specification improvements in care demonstrated by prescribing costs • Set standards high and be prepared to the project work have enabled a new • Established ongoing systematic negotiate around new ways of service specification to be written and monitoring of HOOFs. working agreed with the provider of the new • Take time to understand and assess service, which includes the assessment What are the key learning points? prescribing anomalies. and review of both respiratory and non Use of internal audit to develop systems, respiratory patients. The start date for audit oxygen cost monitoring processes, Contact the new service is planned for Jan 2012 clarify invoices and avoid errors ensured Joanne Watson pending agreement of funding support from the finance and Lead Public Health Development Nurse arrangements and mobilisation of the performance directorate and enabled service. detailed analysis of oxygen usage to be Tel: 07816 271547 undertaken. Email: j.watson11@nhs.net Notable project achievements include: • Validation of oxygen usage completed • Remain motivated in order to deliver in 2010/11 and a further one is eventual improvements planned for November 2011. • Encourage cross functional working – • Register compilation with a system PCT commissioner, medicines now in place to check Home Oxygen management, clinicians and provider Order Forms (HOOFs) are completed properly
- 18. 18 CASE STUDIES NHS Blackpool and Blackpool Teaching Hospitals NHS Foundation Trust Improving oxygen services and the prescribing of oxygen across Blackpool What was the problem? The PCT had a high proportion of patients using oxygen compared to other areas within the region and this was associated with higher than (regional) average prescribing costs. A preliminary audit undertaken in collaboration with secondary care in 2009 revealed that only 30% of patients on home oxygen had been assessed or reviewed by a clinical specialist. This audit identified the risk that patients may be receiving oxygen inappropriately resulting in adverse clinical outcomes if prescribed not matching the patient’s clinical needs or patient in receipt of unnecessary oxygen. What was the aim? The objectives of the project were to: • Develop an accurate home oxygen therapy register What has been achieved? What are the key learning points? • Identify number of patients receiving • £141k pa cost reduction to date • Identify the PCT oxygen lead in order home oxygen who do not meet the • Patients referred seen within a week to progress work utilising concordance guideline criteria • 94% of patients have now been seen reports and supplier invoices and • Identify patients who could have their – in excess of target of 80% of engage the finance dept. in final therapy changed or discontinued patients outstanding at the start analysis work • Conduct urgent review of individuals (approximately 270) • Establish strong links and good receiving high/low dose oxygen to • Now that the team know the patients, personal working relationships ensure clinical risks are managed and have established rapport with between primary and secondary care • Develop a structured them, the consultation time is for a consistent approach to service assessment/follow up service which sometimes shorter, further increasing delivery meets NICE guidance efficiency • Identify all stakeholders, and develop • Increase the proportion of patients • Access to information is now shared engagement and inclusion from the receiving a structured assessment from with the HOS-AR team informing their start, keeping everyone up-dated and the current level (30%) to (80%) clinical decisions and improving quality acknowledge individual and team within time frame of the project. • Blackpool GPs are no longer routinely effort to drive project starting patients on oxygen • Consider what information you need themselves, but are using the service locally, and why, when developing your • Pulmonary rehabilitation is now own data resource to capture and referring into the HOS-AR and vice collect clinic activity, cost savings and versa follow-ups • Community matrons and the early supported discharge service linking with HOS-AR service and expertise shared.
- 19. CASE STUDIES 19 • Effective data collection systems were • Maintaining service efficiency provides essential in order to calculate numbers capacity to ensure DNAs are followed for future capacity and demand and to up by home visits if necessary record the cost savings being realised • Phone call reminders helps to reduce for future sustainability of the Home DNA rate and follow-up phone calls Oxygen Service through improved following a DNA can also help in quality and productivity future attendance rates • Ensure clinicians have access to all up- • Home oxygen service – Assessment to-date relevant patient information in and review within the community a timely fashion in order to make more setting has had both advantages (staff informed clinical decisions at the time can focus exclusively on assessment of contact and review without interruptions • Establishing a robust baseline supports arising from other issues within the realistic and effective planning within acute setting) and disadvantages the resources available, it also helps (community clinic computers not focus and supports identification of currently linked to the appointment quick win reductions in prescribing system) which help team motivation and • Access to expertise with ability to cost provide momentum various service delivery options • Process map early to identify gaps in enabled a range of evidence-based service provision scenarios to be presented to Clinical • Make use of ‘protected time out’ to Commissioning Groups. ensure full engagement from all members of the team with problem Contact solving and action planning Ros Ince • Highlight work that could be more Lead Nurse Diabetes and Respiratory cost effectively performed by administration staff and release clinical Tel: 01253 651316 capacity Email: rosalyn.ince@blackpool.nhs.uk • Changing behaviour is both challenging and evolves gradually over time, pathways revisited regularly through stakeholder meetings, training and support • Working with patients to reduce their prescription where appropriate is difficult and not always pleasant • It is important to consistently promote the message to patients and professionals that oxygen is appropriate only when patients are hypoxic
- 20. 20 CASE STUDIES NHS South Staffordshire Improving home oxygen services through pathway redesign What was the problem? A gap in service provision had been identified within the Cannock Chase locality of South Staffordshire PCT due to the absence of Home Oxygen Service – Assessment and Review (HOS-AR) despite the fact that 537 patients were known to be in receipt of home oxygen within Cannock Chase locality, of which only 149 were known to the local community respiratory team. In addition, the majority of costs associated with oxygen prescribing were attributed to the use of intermittent oxygen or short burst oxygen a therapy modality for which there is currently no supporting evidence What was the aim? Cannock Chase respiratory service reviewed local oxygen treatment in order to: • Rationalise and evaluate home oxygen • Duplicate orders to multiple addresses • Clinicians in GP surgeries have limited prescribing were eliminated as were erroneous knowledge of the type oxygen to order • Establish treatment appropriate to multiple charges levied against and in some cases prescribe clinical need individual patient therapy orders inappropriately • Rectify invoice anomalies and • Established that 64% of the patient • Oxygen assessment and review can • Liberate efficiency gains for investment register had never been previously improve care by ensuring appropriate in permanent HOS-AR provision. assessed and had normal oxygen levels therapy and ensure costs are reflective measured by pulse oximetry of the true clinical need of the What has been achieved? • Supply orders relating to patients who population. • 257 oxygen therapy reviews took place have moved were cancelled and all 257 patients also received a fire • Payment for equipment never received Contact service safety check was stopped. Joan Manzie • 194 patients had their therapy Consultant Respiratory Nurse rationalised as a result of specialist In total, the improvements undertaken review over a six month period achieved cost Tel: 01543 509756 • 30 patients with no clinical indication savings of £130,512 Email: joan.manzie@ssotp.nhs.uk for oxygen had their therapy withdrawn resulting in a saving of What are the key learning points? Sally Young £24,352 • Existing home oxygen data collection Staffordshire Cluster Patch Manager • Cessation of payments made in and administration systems are respect of deceased patients and complex Tel: 03007900233 ext 3538 discontinuation of their continued • Invoicing processes are remote from Email: sally.young@northstaffs.nhs.uk oxygen supply led to a saving of clinicians ordering home oxygen and £23,442 require administrative support to work effectively
- 21. CASE STUDIES 21 Milton Keynes PCT Community Services and Milton Keynes Hospital NHS Foundation Trust Sustaining the efficiency and effectiveness of the Milton Keynes Home Oxygen Service – Assessment and Review What was the problem? Milton Keynes undertook a service Invoice variation 2010/11 (excluding VAT and holiday redesign initiative through a ‘spend-to- HOOF’s and deductions) save’ programme and successfully reduced inequalities in oxygen service 4 provision and also reduced the costs of 2 home oxygen prescribing. However, they 0 were aware that further improvements Jun10 Aug10 Oct10 Dec10 Feb11 Apr11 Jun11 Aug11 % Age Variation Jul10 Sept10 Nov10 Jan11 Mar11 May11 Jul11 could still be made, especially in respect -2 of ambulatory oxygen assessments, and -4 were keen to both sustain and enhance -6 service quality and efficiency by participation in the NHS Improvement- -8 Lung national COPD project. -10 -12 What was the aim? The project team identified three -14 principle objectives: Month • Enhancement of existing care pathway by the production of a HOS-AR (best practice) adoption ladder What are the key learning points? • Improve ambulatory oxygen provision • Clearing the backlog of un-assessed and care by carrying out an evaluation patients has enabled the service to pre and post the setting-up of an reach a steady state in terms of ambulatory oxygen assessment clinic matching demand and capacity • Assess the impact of patient literature • Process mapping exercises uncovered a on patient experience through the gap in service provision in respect of development and use of a quality guideline required home visits and the patient questionnaire pre and post the review of house bound patients. The use of a patient information leaflet. service is confident it can address this gap before the transition to a new What has been achieved? supply contract The service is on target towards ensuring • Sustainable improvements to this that all existing home oxygen patients service were achieved by building have been assessed before the transition An ambulatory oxygen clinic has now progressively on service changes and to a new supply contract. Therapy been established and a patient by ensuring ongoing, coordinated alterations continue to be undertaken satisfaction audit around the use of use and monitoring of oxygen after clinical review and the service has liquid oxygen has been undertaken. In supply data. been able to sustain monthly cost addition, the home oxygen service savings in the order of £1,000 - £2,000 patient information leaflet has been Contact per month. However, the cost saving deployed. An evaluation of the leaflet is Sue Channon trajectory is on the decline as ongoing as the evaluation questionnaire Home Oxygen Commissioning Manager, improvements in ambulatory oxygen was used to obtain baseline findings pre- Regional HOS Lead Specialist, assessment are uncovering the clinical leaflet deployment but as this exercise COPD Co-ordinator need for higher flow rates among many has coincided with another Trust patient patients and so the cost per patient is experience gathering exercise the post- Tel: 01908 650402 rising. deployment evaluation is currently Email: sue.channon@mkchs.nhs.uk outstanding.
- 22. 22 ACKNOWLEDGEMENTS Acknowledgements NHS Improvement – Lung would like to thank all national improvement project sites for their hard work and dedication to improve quality and care for people with COPD, and for their support and contributions to this document. In addition, the following people have provided a source of expertise and support and their help is gratefully acknowledged: • Sandie Bisset Home Oxygen Service, Department of Health • Hamza Jamil Home Oxygen Service, Department of Health • Dr Mike Ward Sherwood Forest Hospitals NHS Foundation Trust • Dr Maxine Hardinge Oxford Radcliffe Hospitals NHS Trust • Bob Arora NHS East London and the City • Glenda Esmond Central London Community Healthcare • Sandra Major NHS Gloucestershire • Yvonne Richards NHS Birmingham East and North • NHS Improvement - Lung References 1. Home Oxygen Service - Assessment and Review - Good Practice Guide, NHS Primary Care Commissioning (2011) 2. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, Department of Health, July 2011
- 24. NHS CANCER NHS Improvement DIAGNOSTICS HEART LUNG STROKE NHS Improvement NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improved patient experience and outcomes. Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements with over 250 sites across the country as well as providing an improvement tool to over 2,000 GP practices. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow’s Publication Ref: NHSImp Lung 0001 - May 2012 ©NHS Improvement 2012 | All Rights Reserved improvement agenda for the NHS