Discharge planning for people with chronic obstructive pulmonary disease must be improved, says a report that found more than 40% end up back in hospital after three months.
The National COPD Audit Programme found 43% of patients admitted to hospital for COPD in 2014 were readmitted at least once in the three months after they were discharged.
“It is vital that primary, secondary and social care services work better together”
This represents a significant increase from the 33% re-admission rate in 2008, said the programme’s latest report published today by the Royal College of Physicians.
The audit results did show some improvements, including fewer COPD patients dying in hospital and also soon after being discharged, and a reduction in the average amount of time patients with severe exacerbations spent in hospital.
However, it said the high number admitted and re-admitted to hospital showed services were not meeting the needs of a vulnerable group, especially older patients that had other health problems.
More than half of those re-admitted to hospital in 2014 were older people with multiple health conditions, the report said. Many patients had also been in hospital relatively recently, with more than half admitted on a previous occasion in the six months leading up to the audit.
“The over-riding impression provided by the data is of a system that is not only stressed but is ultimately failing COPD patients,” warned the report.
“We have to think beyond the old divides if care is to be effective and sustainable”
It highlighted the need for improved discharge planning by hospital teams, particularly for vulnerable and frail patients, looking at the “total needs” of people with COPD.
When patients were sent home they should be reviewed early on – within seven days – by community teams, highlighted the report.
Meanwhile, it also called for more work in primary care to identify high-risk patients and provide support to stop them needing to go to hospital in the first place.
Dr Robert Stone, a consultant respiratory physician at Taunton and Somerset NHS Foundation Trust and clinical lead for the audit, said one of the key messages was the need for more integrated care.
“It is vital that primary, secondary and social care services work better together to support people suffering from COPD, placing them firmly at the centre of their own care,” he said.
Specialist nurses could play a key role in shaping and delivering more seamless services, added Carol Stonham, nurse lead for the Primary Care Respiratory Society UK.
“There is so much for people with COPD to gain if we work, as this report suggests, in an integrated way across traditional boundaries,” said Ms Stonham, a primary care respiratory nurse specialist in Gloucestershire.
“We need to share what we know to identify the most high-risk patients – to utilise the passion and knowledge of respiratory specialists in secondary and community care to enhance the offer to these patients who manage their illness in the community,” she said.
“We need to work with social care to enable patients to get home more quickly with the right support. We have to think beyond the old divides if care is to be effective and sustainable for patients with COPD,” she added.
The report said commissioners should ensure integrated COPD care was widely available and incorporated into sustainability and transformation plans for their region.
It also called for commissioners to review key services – often delivered by nurses – that can play an important role in reducing hospital admissions and re-admissions, such as pulmonary rehabilitation, smoking cessation support and community palliative care.