Meet the team: CLEMATTIS- COPD Lung Education, Management and Treatment Through Integrated Support
Senior Programme Development Lead- PSC
Health Innovation Manchester
- England - national
- England - North West Coast
- Cathryn Winchcombe, Directorate Manager Medicine
- Natalie Young, Deputy Directorate Manager Medicine
- Dr Bhatia, Respiratory Consultant
- Dr Abdelaziz, Respiratory Consultant
- Heather Palmer, CCG
- Dr Gideon Smith, Consultant Public Health
- Michelle Cunningham, Specialist Respiratory Nurse,
- Catharine Cornell, Specialist Respiratory Physiotherapist
- Dr Asad Ali, GP Neighbourhood lead Denton Neighbourhood
Tameside and Glossop has one of the highest COPD prevalence figures across the North West and continually high rates of admissions for COPD (8,588/1,000 population) compared to the North West (6,200/1,000) and England (4,698/1,000). Mortality in Tameside and Glossop in 2016 was approximately 2,000, of which 657 of these (31%) were respiratory related. Respiratory disease has the highest mortality rate within Tameside and Glossop ahead of cancer and heart disease. As part of a currently identified system-wide Respiratory Pathway Programme to address these health inequalities, the Service Improvement Manager organised some workshops with a wide range of stakeholders across the community and acute settings. Great discussion and engagement has meant that numerous ideas have been developed within these workshops which are forming the basis for new service offers, closer MDT working, and GP-based stratification and engagement of individuals with pre and current COPD. We have scoped initial data around where we can have the most impact, looking at ‘frequent fliers’ and the neighbourhoods they live in, support from digital offers and third sector agencies, and patient feedback on what elements they feel are missing for them.
At each workshop held there has been a lot of discussion around how COPD patients are supported with information and advice, and how this could be delivered in a way that the individual would ‘take on board’ more. Patient feedback about how this could be achieved focussed on ‘buddy’s’ and how talking to someone who also has COPD makes receiving and believing this information far more effective. A lot of material is shared with patients in the acute setting which often becomes a large pile of disparate leaflets and information sources which they never refer to again, or only do so when they have an exacerbation or emergency episode. Many of the teams who have developed these materials are trying to promote self-management and self-care as way of increasing psychological wellbeing i.e. smoking cessation, pulmonary rehabilitation, exercise to extend function. Key to all of these is the patient believing the information and that the support will work for them; which is where using a peer support network of COPD individuals to share and discuss this would work well. There is also some thought around developing a patient held care plan which could be kept within the bag for completion by all healthcare parties to support cross pathway care. A clear flower logo (Clematis) on the bag and any resources developed would indicate the COPD outcomes as part of this Q-Exchange initiative.
We would expect that patients will feel an increased sense of confidence when managing their COPD condition (PAM or similar metric), know who to contact for support (n= referrals to pulmonary rehabilitation, respiratory physios and nurses), link into health promotion services (n= smoking cessation referrals, Live Active exercise classes) and appreciate that there are people similar to themselves who manage their conditions well. Staff are keen to make sure that the education and management information they produce and sessions that they offer provide the best support for COPD patients. Uptake on pulmonary rehabilitation would be a key outcome, alongside reduced readmission rates, reduced length of stay and activation around medicines and inhaler technique. Using a group of peer support individuals to engage with patients should develop new working relationships within both healthcare professional groups and third sector health and wellbeing organisations.
The support from this funding would give us a great resource that could be shared across any healthcare organisation working with COPD or any other Long Term Condition group as the idea has transferable objectives. The Q Community would be able to use the template/ idea for peer support engagement work within their own organisations, and hopefully the Clematis logo as an identifier for cross pathway work. We envisage that we would share the outcomes from our work through a Blog, Twitter for our developed CLEMATTIS logo, training and education resources; and patient stories for impact
How you can contribute
- What resources would be good to include?
- Have you developed any cross-pathway patient-held care plans?
- Have you used virtual engagement options e.g. Tablet based Apps etc, in peer support conversations?