EMBRACE Severe Asthma Programme
Norfolk & Waveney ICB
Practice Pro-Forma
A new virtual Severe Asthma case finding, and remote triage service is being run for patients across BLMK ICS.
Effective population-wide management of severe asthma (as defined by BTS guidelines) represents a significant challenge to local health systems. Delays to identification, and referral, combined with long specialist waiting lists means many patients are being sub-optimally managed for too long. – Across England, we see that over 4000 pts have received more that 4 courses of oral steroid in the last year alone but only 17% have been initiated on guideline indicated biologic therapy. With greater than 7000 pts across England estimated to have a severe form of asthma – a more efficient method of identifying, assessing, and referring this cohort of patients is required.
We are seeking to support primary care across Norfolk & Waveney by remotely reviewing, risk stratifying, and directly engaging with patients, and for those that consent - efficiently managing the essential baseline testing (FeNO, Spirometry, blood Eosinophils), and the onward referral to specialist clinic of those patients identified as meeting the national severe asthma referral criteria.
Patient education will be provided to all participating patients and a comprehensive individual report will be sent to GPs on completion of each review. No onward referral, prescribing decision, or contact will be made with patients without explicit GP prior consent.
The aim of this project is to efficiently identify and manage those patients with poorly controlled and sub-optimally treated severe asthma. It is being lead by the severe asthma specialist consultant service for the region.
Patient engagement will be provided through the ECLIPSE interface (NHS Pathways).
Your eligible patients (see initial triage criteria below) will be sent a text, using our patient engagement platform PEGASUS (Patient Engagement Governance Assuring Standardised User Support), the text directs them to a patient information zone - Norfolk & Waveney Asthma Review (nhsconnect.org) where they can access their patient portal to complete a questionnaire, where their relevant history and personal preferences regarding this project can be registered.
INITIAL TRIAGE CRITERIA
Diagnosis of asthma OR on regular inhalers with no diagnosis of respiratory disease
AND
≥ 1 emergency admission in last 12 months (respiratory)
or
≥ 6 SABAs in last 12 months
or
≥ 2 prescriptions of oral steroids (or recorded asthma exacerbations) in last 12 months
or
≥ 5mg maintenance oral steroids
Patients fulfilling these initial criteria are then contacted and further stratified based on regional MDT criteria (see flow diagram).
This information zone will allow patients who are hearing or sight impaired to let us know their preferences for the programme and is equipped with translation services for 20 of the most common languages spoken in the UK to ensure equity of access.
Patients identified as being at high risk will be invited for a virtual screening appointment by the ECLIPSE Patient Support Team (Putting Patients First), and to have their baseline investigations carried out at either their GP practice (for those surgeries indicating in-house interest) or locally at a pop-up clinical treatment hub. In the first phase, those patients meeting the agreed threshold for specialist review will be referred on to the local specialist asthma service via the existing ICS approved referral pathway by their GP. (N.b. Phase 2 of this work would seek to deploy a streamlined referral route for remotely reviewed patients).