Blueprint COPD Services (1/2)
Health and
Wellbeing
Self and Informal
Care
New Primary Care
EXAMPLE
New anti-smoking campaign, well-coordinated and consistent across all health and social
care providers
Identification of people with risk factors for COPD and referral to GP for screening
Patient support groups for smoking cessation and for coping with COPD
Self-monitoring for FEV1 and state of respiratory health and level of functioning
Self-starting Abx and steroids for exacerbations
Relaxation (meditation, behavioural therapy methods) to reduce anxiety
Patients (and carers) are part of care planning and have access to care plan (incl.
workflow plan)
Telemetry is available where remote monitoring enables greater independence
Friends & family support for patients for daily living
Local voluntary organisations are part of the support network
Supported housing and domiciliary care (where necessary) reflects the needs of COPD
patients
Proactive case seeking for people with risk factors and screening
Proactive risk monitoring and early intervention
Enhanced smoking cessation courses (with psychol. support) to achieve higher longterm quit rates
Repeated pulmonary rehab (ideal frequency to be agreed)f
Patient education, incl. focus on inhaler technique
24/7 availability to respond to urgent patient calls
Rapid access to telephone advice by competent clinician who has access to patient
records and care plans
Complex cases are discussed and advised in MDTs with specialists
Complex cases have a named lead clinician who is in charge of coordinating all care and
who is the main point of contact for the patient
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Blueprint COPD Services (2/2)
Mobile Clinical
Services
Urgent Transfer
New Secondary
Care
System Enablers
EXAMPLE
Immediate response to patients with shortness of breath – assessment treatment
attempt by mobile clinician with relaxation, nebulisers, oxygen if needed
24/7 ability to check with NPC about baseline level of patient status – conveyance only
if status worse and initial treatment not working after adequate trial time
MCS aware of all available service alternatives at any given time to help patient select
preferred route of further care, when needed
To A&E for respiratory distress only
To GP practice in hours
Potentially transfer to intermediate care beds in community after assessment by GP, or
Mobile Clinician
Consultant expertise available to advise NPC without referral for urgent calls and for
regular MTD sessions were complex, high risk cases can be discussed
Diagnostics (imaging and spirometry) available by direct access and in community
outposts
Hospital clinicians have immediate access to up-to-date clinical records and care plans
from New Primary Care
OPD can directly refer to smoking cessation and pulmonary rehab
NELIP services discharge patients with discharge package that focuses on secondary
prevention
Discharge preparations from hospital involve New Primary Care to ensure seamless care
In-hospital services for patients with multiple LTCs are well coordinated
Reimbursement by YOC tariff to a lead provider (ICO?)
Formation of an organisational entity for New Primary Care (ICO?)
Improved information flows through better IT system links
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