Chronic Obstructive Pulmonary Disease Workstream
The Hunter Alliance COPD Workstream team developed and piloted processes across primary care, hospital and RACF settings to optimise diagnosis, care planning and management of people with COPD.
The pilot phase was conducted between February and June 2015 in order to develop and test processes across one general practice and one Residential Aged Care Facility (RACF). The goals of this pilot phase were:
Early identification of people with COPD in a primary care setting;
Accuracy of diagnosis of people with COPD by primary care providers;
Identification of treatment goals to optimise care for people with a diagnosis of COPD;
Provision of timely specialist advice and care;
Partnerships between tertiary care and primary care in a whole of health systems approach.
The project demonstrated that a virtual model of access to medical specialist review and advice, accompanied by upskilling of primary care nurses by specialist nurses in general practice and aged care settings, can improve the care of patients with COPD. This study achieved improvements in the accuracy of diagnosis, appropriate use of medication, inhaler technique, rates of immunisation, attendance at pulmonary rehabilitation and written COPD action plans which are all important to optimise care for people with COPD. Patients also reported a good experience of care and staff reported a range of benefits and learnings from the study.
The workstream in currently considering: - planning for spread to further GP Practices and Residential Aged Care Facilities and disease groups; - development of resources to allow sustainability via “Train the trainer” and supportive protocols and tools, including a “Care Passport” and guide for utilising existing available funding sources; and - GP with Special Interest development program.
Picture: GP Education Evening
Work streams are clinically-led and supported by key people from across the primary and secondary sectors.