Leading change

A Chronic Obstructive Pulmonary Disease (COPD) Specialist Nurse at Solent NHS Trust led on the refinement of personal care planning based on Patient Activation Measure (PAM) scores within respiratory services. The project has led to improved engagement, outcomes and experiences for those using respiratory services at the Trust.

Where to look

NICE (2016) identify that people admitted to hospital for an acute exacerbation of COPD should start a pulmonary rehabilitation programme within 4 weeks of discharge as this reduces the risk of readmission. As a part of these quality standards, pulmonary rehabilitation is the evidenced-based treatment approach for COPD, based on exercise and management techniques for breathlessness. Such rehabilitation is cited to improve quality of life.

Southampton integrated COPD team provide care across the city for people with COPD following their discharge from hospital, providing pulmonary rehabilitation in the community. The nursing team identified, however, that a significant number of patients were unable to complete the course of rehabilitation and therefore were increasingly reliant on emergency care when their condition deteriorated. This was resulting in increased attendance at hospital and avoidable stays in hospital. This unwarranted variation presented an opportunity for a nurse-led improvement initiative.

What to change

The senior nursing and project lead conducted an audit within the COPD service to understand what current service provision looked like and to identify areas for improvement. The findings identified that many patients were not engaging with pulmonary rehabilitation (either not attending the first sessions or not completing the course).

Current pathways and treatment options for COPD patients included standard self-management using actions plans and pulmonary rehabilitation. However, this was not addressing the needs of approximately a third of the local COPD population. There was a trend towards people repeating the rehabilitation courses without improvement, not being able to respond to their symptomatology in a crisis and increased hospital attendance. The COPD specialist nurse saw an opportunity to personalise or tailor the care plans to truly advocate and support more independent self-management.

This evidence highlighted that this was specifically the case for people with lower levels of knowledge, skills or confidence in managing their condition as recognised by low Patient Activation Measures (PAM).

NHS England describes ‘patient activation’ as the knowledge, skills and confidence a person has in managing their own health and care. Evidence shows that when people are supported to become more activated, they benefit from better health outcomes, improved experiences of care and fewer unplanned care admissions. By understanding people’s activation levels, staff can support people, particularly those with Long Term Conditions (LTC), in a tailored manner. The Patient Activation Measure (PAM) is a tool that enables healthcare professionals to understand a patient’s activation level, or their level of knowledge, skills and confidence to manage their LTC.

PAM involves individuals completing a short survey and based on their responses, they receive a PAM score (between 0 and 100). The resulting score places the individual at one of four levels of activation, providing insight into a range of health-related characteristics, including behaviours and outcomes. The four levels of activation are:

• Level 1: Individuals tend to be passive and feel overwhelmed by managing their own health. They may not understand their role in the care process.
• Level 2: Individuals may lack the knowledge and confidence to manage their health.
• Level 3: Individuals appear to be taking action but may still lack the confidence and skill to support their behaviours.
• Level 4: Individuals have adopted many of the behaviours needed to support their health but may not be able to maintain them in the face of life stressors.

Within other areas of the Solent NHS Trust, PAM were already being used with promising results. This provided local evidence for PAM-based intervention for those with COPD. The team focused primarily on those individuals frequently using emergency services with PAM level 1 scores. This supported a targeted intervention to support these individuals to develop their knowledge, skills and confidence. It was anticipated that this approach would support them to progress through the PAM levels and associated better outcomes.

How to change

The PAM tool was embedded into clinical assessment processes where staff were provided education and training to use the tool and regarding benefits. During routine COPD assessments, the PAM tool was completed by the patient with the support of the specialist team and their baseline level of activation was identified. Clinical pathways were reviewed and refined to include the tool, to tailor discussions and personalise the provision of support.

For patients with low PAM scores, this tailored nurse-led intervention was either at home or in a clinical setting, on a one-to-one basis. This intervention was defined as personal care planning (PCP). These patients are seen by the specialist nurse who has extensive COPD knowledge and is trained in motivational interviewing. The team developed an interactive approach to PCP, using constructs such as: “What matters to you?’’, basic motivational interviewing skills, clinical care (to ensure clinical safety) and shared goal-setting. This informed the personalised intervention for these patients. The care plans are heavily based on small goals, set by the patients themselves, including what they would like to change in their lives, based on an overall larger goal to aim for.

The progress of this refined care planning is routinely collated which allows the team to measure the impact of the service.

Adding value

Better outcomes – There has been a noticeable improvement in the PAM scores. These demonstrated an average improvement of 10 points in a patient’s activation level. The PCP intervention has enabled the team to provide a more in depth, tailored self-management intervention in this cohort of patients.

Better experience – The team report they now feel equipped to provide the right care, at the right time. This is particularly apparent for patients who require more input. Taken together, staff and patients have welcomed the new approach to care and assessment. Indeed, patients have responded very well, with specific outcomes and experience improvements associated with individual goals. For instance, smoking cessation and increases in activity. An example of staff feedback:

“The PCP PAM approach has significantly changed the way I approach a patient consultation. Active listening…and developing a true patient led way of working is difficult, as you want to always suggest options. But it does yield excellent patient experience and long-term health changes, because the patients really want to make that change for themselves.”

Better use of resources – The main impact has been on the use of pulmonary rehabilitation. Staff recognise that such rehabilitation may not be appropriate for all patients. The refined care planning and personalise approach to care advocates more tailored one-to-one support and this is influencing a better use of resources.

Challenges and lessons learnt for implementation

This approach to care has seen a change in thinking and practice within the service, including the approach to consultation conversations and the value of shared goal setting and supporting patients to understand the different components of a complex condition.

It can be challenging to implement changes to a well-established structure. With time, staff have embraced this and the early evidence of success based on the PAM scores is showing signs of it being embedded into the service.

Following the success of the programme, the PCP intervention is being developed in conjunction with the University of Southampton as a wider complex intervention to be used with all patients with PAM level 1.

For more information contact

Lindsay Welch
Long Term Conditions Lead Nurse and Project support officer
Solent NHS Trust
Lindsay.Welch@solent.nhs.uk

Sue Batchelor
COPD specialist nurse
Solent NHS Trust
Sue.Batchelor@solent.nhs.uk