Right People at Right Time: An Innovative Approach to ILD Management
Dr Ruth Williams, ILD Clinical Lead / Respiratory Consultant
Natalie Murray, ILD Clinical Nurse Specialist
Joanne Wheeldon, Specialist Respiratory Pharmacist
Rebecca Griffiths, Respiratory Physiologist
Cwm Taf Morgannwg University Health Board
The Interstitial Lung Diseases (ILD) are a diverse group of conditions that may be progressive and ultimately fatal. Therefore, timely access to specialist care, diagnostics and appropriate support during the course of the illness is crucial. This is certainly true for one particular condition, Idiopathic Pulmonary Fibrosis (IPF). IPF is an incurable and progressive lung condition and the current mean survival is 2.5-3.5 years following diagnosis. We propose delivering a new model of service for our patients, utilising the expertise of a number of allied health professionals to deliver high quality, evidence-based healthcare in a timely manner.
One of the primary aims of this project was the development of the pharmacy-led service. By utilising the skills of a prescribing pharmacist it would reduce consultant and specialist nurse work load, reducing waiting times and provide access to a specialist prescriber.
Another facet of this project was the innovative physiology-led (P-ILD) service. At this one-stop review patients with stable disease would receive their lung function test and clinical review by our physiologist – saving multiple appointments.
- Improved patient experience
- Tailor management of patient to their specific needs
- Stream-line patient pathway
- Earlier diagnosis and intervention
- Healthy patients due to lifestyle changes/ modification interventions
- Self-management plans including avoidance of side effects/ optimisation of therapy
Service Improvement Aims
- Reduce consultant follow up waits for patients with ILD
- Reduce repeated planned hospital attendances
- Reduction in unplanned hospital attendances through improved education, hot slot clinic reviews and advanced care planning
- De-prescribing of unnecessary medication
- Cost savings of developing virtual clinics compared to the traditional model
- Allow wider development of the service to include improved better access of palliative care and education provision to primary care
- Funding for our pharmacist – identified as a risk from the start and one that was never fully overcome. Goodwill from our pharmacy colleagues allowed for a brief period of time to train and deliver clinics resulting in our limited, but highly positive data.
- TB outbreak – a large outbreak in a prison diverted the services of our specialist nurse. Whilst this meant she was unable to focus on other areas of the development, having the pharmacy-led service provided essential continuity of care to our patients.
- Covid-19. A respiratory project in the middle of a respiratory pandemic; need we say more?
Time to first appointment and diagnosis was significant reduced through a combination of service improvements from January 2019 (including the MDT approach to follow up) for our IPF cohort.
Our pharmacist-led clinics were only operational (due to challenges discussed) over a 2 month period and in that time 29 patients were reviewed.
100% of patient had lifestyle factors, compliance and side effects discussed. 97% of patients had their medicines reconciled and as a result there were interventions made in 43%. As well as experience outcomes, this service also ensures safety for our cohort on toxic therapies.
Our pharmacy –led service was very well received by patients, with 75% agreeing they were happy to see a pharmacist instead of a nurse or doctor.
- We have reduced the patients under consultant follow up by 86% (excluding deceased patients). It should be noted that prior to this intervention these patients were still having appointments with physiology / nurse as well as consultant. This reduction in consultant time has allowed for reduced waiting times and hot clinic appointments to review patients within 2 weeks.
- There is also a significant cost saving of approximately £268 per clinic (consultant vs nurse/ pharmacy-led).
- Those under P-ILD have reduced the number of appointments they need to attend by 50%
- There is also a potential cost saving through thorough medicines reconciliation. In our small sample size, 14% had medicines de-prescribed and these reviews also reduce risk of side effects.
- We adopted the virtual clinic review for our nurse / pharmacy led services pre-Covid – but these will continue to include the majority of the consultant clinics, further reducing costs but also improving patient experience.
- Developing a business case to ensure that our pharmacy-led service can continue.
- Focus on our advanced care planning service improvement to improve patient experience and try to reduce unplanned hospital attendances
- Pending NICE approval, a wider cohort of our patients will be eligible for these high cost drugs so we need to ensure we can meet these additional needs through MDT working
- Incorporating the novel post-Covid ILD patient cohort into our service in an efficient manner
- Adopt and spread this approach within respiratory and the wider medicine community.
Our Exemplar Experience
We have found the Bevan experience to be inspiring and a positive encouragement to persevere with innovation.
Bevan Exemplar Showcase 2021