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Developing an integrated model of care for COPD

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Serginson, J. (2007) Developing an integrated model of care for COPD.

VOL: 103, ISSUE: 35, PAGE NO: 28-29

John Serginson, MCN, BN, Grad Dip Nurs Sc (crit care), Cardiothoracic Cert, RN

Thoracic clinical nurse consultant, The Prince Charles Hospital, Northside Health Service District, Queensland,Australia.

COPD is a disabling condition that consumes significant healthcare resources. Within the Prince Charles Hospital Health Service District, respiratory clinicians recognised a number of limitations with existing services, including suboptimal communication of patient information, variability in clinical practice, and limited or inequitable access to services such as pulmonary rehabilitation and smoking cessation. The ‘Strengthening the Respiratory Care Continuum’ project was undertaken to review the existing model of care and associated processes and services for people with COPD. This article describes the model and its development into a blueprint for ideal care for patients with COPD.


COPD is a disease state characterised by airflow limitation that is not fully reversible and is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases (Pauwels et al, 2001). It is highly prevalent; applying Australian prevalence rates to local 2001 census data produces an estimate of approximately 45,000 people living in the Prince Charles Hospital Health Service District (PCHHSD) with COPD (Wilson et al, 2002; Abramson et al, 2001).

The PCHHSD is a state government-funded service providing both acute care and community health services to the local population of approximately 550,000 residents on the north side of Brisbane, Australia. The airways clinical management (quality) team, whose members represent all disciplines from acute and community health services, identified a number of issues with existing services. These included limitations in processes for communicating patient information between healthcare providers (fragmented care, service duplication and unmet needs), variability in clinical practice, and limited or inequitable access to services (pulmonary rehabilitation, smoking cessation, patient education). ‘Strengthening the Respiratory Care Continuum’ was a project undertaken in 2003 to review the existing model of care and associated processes and services for people with COPD. The main objective of this collaboration between the thoracic and community services programmes was to develop a consensus model of care for patients with chronic respiratory problems in PCHHSD. In addition, the project sought to identify strategies to improve the flow of patient information between health service providers, revise the existing community health nurse home-visiting programme for patients with COPD and to develop an accessible patient education service. The first aim is discussed in this article.


In Australia two tiers of government are accountable for healthcare funding. Primary care, such as GP services, is predominantly provided by privately owned practices on a fee-for-service basis, for which federal government-funded rebates are available through the Medicare (universal insurance) scheme. State government health departments such as Queensland Health provide secondary and tertiary care as well as community health services. Private hospitals also provide fee-for-service secondary care, which is predominantly accessed by individuals with private health insurance.

COPD consumes significant healthcare resources in PCHHSD. In 2002, 420 clients with COPD had 612 admissions and an average length of stay (ALOS) of 6.3 days, which consumed approximately AUS $3 million of inpatient care, with 16% being readmitted within 28 days of discharge. This compares with 607 admissions by 391 clients in 2000 at a cost of $3.9 million (ALOS 7.9 days) and a 28-day readmission rate of 17%. The emergency department received 1,415 presentations for COPD between January 2000 and December 2002 (averaging 470 per year), of which 1,169 (83%) were admitted.

An outpatient pulmonary rehabilitation programme for better breathing runs with 100 places per year over seven weeks. Access to the programme is limited by the number of available places on the course, session times, course location and referrals being limited to patients of The Prince Charles Hospital. In 2002, community health nurses saw 144 people on 202 occasions for respiratory issues in the district.


Traditional models of care have been based around specialist and general medical services, with the acute care hospital episode as the focal point of the model (Thrall, 2005; National Public Health Partnership, 2001). A referral - usually medical - initiates the episode and it concludes with discharge to primary care follow-up.

Allied health and nursing services traditionally parallel this acute care medical model, which has worked efficiently for patients without comorbidities who experience an acute illness or injury and can expect full recovery within a short time frame. However, only a small percentage of our patients today would fit this description. Most have some comorbidity and many have several chronic illnesses that require ongoing monitoring and care from a number of health disciplines. A study of 980 primary-care patients found that more than 90% of those over 45 years had two or more chronic conditions (Fortin et al, 2005).

The ideal features of an effective model of care for chronic conditions were identified through review of the COPD and chronic disease management literature (Hernandez et al, 2003; Anderson et al, 2001; Ferraro et al, 2001; Poole et al, 2001; Wagner, 1998; Brown and Caplin, 1997). The complex care needs of people with chronic conditions have been considered in the construction of the model of care for COPD that has been developed through the process outlined below.

Multiple strategies were used to gather information in the project. These included accessing activity data for hospital and community health services, consulting with stakeholders through focus groups and surveys, reviewing published literature, consulting with other respiratory services, and attending the inaugural ‘Patient Needs: Managing Hospital Demand’ conference. The conference featured presentations of service models and outcomes by clinical service projects that were funded by the Victorian Department of Human Services under the hospital admission risk programme. The findings of the project are outlined in Box 1.

Box1. Project findings


  • Core interventions offered in integrated COPD services include pulmonary rehabilitation, smoking cessation clinics, individual COPD education and self-management plans;
  • Common additional services include hospital in the home (HITH), respiratory outreach services, maintenance pulmonary rehabilitation and case management;
  • Rapid access to specialist outpatient clinics can successfully reduce avoidable admissions, particularly in conjunction with outreach services, HITH or case management;
  • Tools and strategies that enable timely communication of patient information between all health team members are vital to the success of an integrated care service;
  • Core interventions for COPD in PCHHSD are offered with the exception of self-management plans, although these services are not equitably accessible;
  • All successful respiratory services with an integrated model of care have a clinical champion - a physician with clinical and research expertise in COPD leading change in service delivery.

Model development

The ideal features of an effective model of care for chronic conditions were identified through literature reviews, consultation with other health services providing care for chronic conditions, discussion with local stakeholders and the experiences of clinicians within PCHHSD and the results of the project. These were determined as:

  • Patient focus in the community/home setting;
  • Maintenance phase central to the model;
  • Emphasis on self-management principles through education, support and motivation;
  • Application across a broad spectrum of disease severity, disease impact and care needs;
  • Consideration of the natural course of COPD, that is functional decline over time with acute exacerbations;
  • Linking existing evidence-based services to proposed additional services as per national guidelines;
  • Defined key areas for communication between team members;
  • Having a practical model that is intuitively sensible to stakeholders;
  • Ability for the model to be realistically implemented locally within available structures.

The draft model was then developed as a synthesis between the COPDX guidelines (McKenzie et al, 2003)and chronic disease management principles to reflect the relationship between our current COPD services and new services proposed to fill existing gaps. Recommendations of the COPDX guidelineswere separated into the three phases of the model - establishment, maintenance and transition - and core services associated with these recommendations were listed separately.

Following presentation and explanation of the draft model to a number of stakeholder groups, a copy was circulated with a survey. Feedback from clinicians of all disciplines from acute and community care sectors was incorporated into the revised model (Fig 1).

A comparison of the COPDX and NICE COPD guidelines (NICE, 2004) reveals the expected consistency in recommendations although some differences are worth noting. NICE alone recommends considering short-burst oxygen therapy for severe breathlessness. Both guidelines discuss self-management plans and hospital in the home for exacerbations, but NICE provides more specific detail in its recommendations. This is likely to reflect the earlier adoption of these strategies in clinical practice in the UK and Europe compared with Australia

Description of the model

The model describes our vision for ideal healthcare for COPD patients across the spectrum of disease severity, towards which we are working in our health district. Any clinician in acute or primary care can refer patients to the continuum of care that the model describes, if they meet the following criteria:

  • A spirometry-confirmed diagnosis of COPD as per COPDX guideline criteria (McKenzie et al, 2003);
  • Lives in the district and consents for healthcare providers to share their clinical information.

It is anticipated that initially, suitable patients will be primarily identified during inpatient episodes for exacerbations or at specialist outpatient clinic appointments. Over time, referrals will be encouraged and accepted from all points in the continuum, most importantly from primary care.

The model comprises three phases - establishment, maintenance and transition - that are described below.


This phase may last between one and eight weeks and aims to:

  • Complete a detailed assessment of the patient’s disease severity, complications, functional status and their ability to manage their condition;
  • Enable access to all COPDX-recommended interventions as appropriate to the patient’s current needs and preferences.

Interventions to be considered for implementation in this phase are:

  • Confirming or supporting the diagnosis;
  • Assessing disease severity and complications;
  • Review by a respiratory physician review;
  • Medications and vaccination;
  • Pulmonary rehabilitation or individual exercise plan;
  • Plan to give up smoking;
  • Individual COPD education;
  • Chronic disease self-management course;
  • Support group referral;
  • Written self-management plan for maintenance and exacerbations;
  • Multidisciplinary care plan.

The healthcare provider(s) most appropriate to complete or refer for each intervention are indicated on the model.

An establishment phase checklist has been developed to support the documentation and communication of interventions conducted in this phase and can be initiated by any healthcare provider. On completion of the establishment phase, the patient/carer and all members of their care team will have a detailed understanding of:

  • The patient’s condition, its severity and symptoms;
  • The patient’s personal and health-focused goals;
  • Daily activities to meet these goals (medications, exercise, diet, relaxation);
  • Planned activity to prevent deterioration and optimise function;
  • Early signs that indicate an exacerbation and actions to be taken by each party.


Maintenance phase

For the majority of patients, the maintenance phase is where they will spend most of the time. The aim of this phase is for prospectively planned and integrated reviews of the patient’s progress towards their goals and clear communication of assessments, interventions and outcomes to all members of the care team including the patient. Appointments with different members of the care team are timed strategically to maximise support, minimise duplication and enable the implementation of an integrated ongoing plan of care.

Aspects to be reviewed regularly include:

  • Spirometry, complications, quit status of current and recent ex-smokers, and functional status;
  • Actions taken by patient as part of a care plan (exercise, diet, medication, oxygen);
  • Coping skills, knowledge, quality-of-life and self-management skills;
  • Self-management plan;
  • Patient’s progress towards their goals.


The disease impact of COPD on the person’s life varies widely depending on disease severity, coping skills, available support and other comorbidities. The model reflects that the care team members also vary according to care needs. All patients are expected to have a GP as their primary medical carer, but in addition, those with higher disease impact will have some or all of the following in their maintenance care team: community health nurse, community or acute care-based allied health professional, respiratory specialist, respiratory nurse.



Patients who have been referred to the community health nurse COPD programme receive structured home visits post discharge from hospital and ongoing maintenance visits or phone support as required. For those with severe COPD who frequently use inpatient or emergency department services, the community-based respiratory nurse will function in the role of care coordinator with the aim of providing regular and as-needed access to intensive support to improve quality of life and promote more appropriate resource usage.

Transition phase

The transition phase describes the period of time during which the patient experiences an increase in the intensity of care required due to an exacerbation of COPD. The emphasis of this phase is onthe recognition of the early signs of exacerbation by the patient/carer and prompt action as described in the self-management plan. Rapid access to the appropriate level of assessment, interventions and support quickly follows patient-initiated changes to medications as per the plan. Assessment may take the form of GP review, community health nurse home visit, rapid access to respiratory specialist obstructive pulmonary disorder clinic or emergency department and review depending on the previous plan and the severity of current symptoms. Supportive interventions may include one of the following:

  • Community care - more frequent community health nurse visits, GP review and extra medications;
  • Hospital admission - usually 6-7 days;
  • Hospital in the home service - daily to second daily respiratory nurse home visits;
  • Brief hospital admission of 2-3 days with supported early discharge.

The intensity and frequency of assessment, treatment and support is stepped down as the patient improves. Patients with COPD who are admitted for hospital-based acute care are referred to the community health nurse COPD programme before discharge. They receive structured home visits post discharge with the aim of assessing progress and reinforcing the education provided while in hospital. The transition phase continues through to recovery (2-6 weeks later), where the patient re-enters the maintenance phase after baseline care requirements are reassessed and their self-management plan is re-established.

Improved communication of patient information between health team members (Box 2) is achieved through the following strategies:

  • A fax to the GP and community health nurse or allied health professional advising of admission;
  • Nurse and allied health input into medical discharge summaries with a self-management plan;
  • Discharge summaries and outpatient review letters sent to all team members as opposed to the GP alone;
  • Summary from nurse or allied health home visit sent to GP and added to patient’s hospital chart;
  • Tele case conferences prior to discharge for clients with complex situations;
  • Post-discharge appointments booked before discharge (specialist obstructive pulmonary disorderprofessional, community health and GP).


Box2. Improved communication of patient information



Tools and strategies that enable clear communication of patient information between team members during the maintenance phase:


  • Outpatient review summaries (medical, nursing and allied health) to be forwarded to all other members of the care team;
  • Community health assessments and review summaries (nursing and allied health) to be sent to GP and added to the patient’s hospital chart;
  • Phone calls made to clarify issues or access information known to be held by another team member;
  • Self-management plans are held by the patient with copies files in the hospital chart and sent to the GP and community health nurse (faxed, posted or via the patient);
  • Access to standard patient education resources and assessment tools online;
  • Access to standard patient education resources and assessment tools online.


The model describes ideal care towards which our clinical management team and health services district are working. One of its limitations is the incorporation of such a wide range of component services provided by different health service organisations, with disparate funding models, aims and service delivery practices. Enabling collaboration between different groups and individual clinicians remains a significant challenge. Identifying and aligning the drivers that influence service providers and discussion and collaboration on individual cases remains our principle strategies to address this issue.

To date, many aspects of this integrated model of care for COPD - hospital in the home, rapid access outpatient clinics and community-accessible pulmonary rehabilitation - are yet to be fully implemented due to funding issues. Nonetheless, the outcomes of the development of this model have included the implementation of a revised community health nurse COPD programme, the establishment of a community-based respiratory specialist nurse position and a common focus for community and acute care-based service planning including the Queensland Strategy for Chronic Disease Management (Queensland Health, 2006). Recurrent funding has recently been secured for a ‘hospital in the home’ service for the district.


This model describes our vision for ideal healthcare for patients with COPD across the spectrum of disease severity within our health district. It is also an example of the leading role nurses can, and often do, play in shaping the revision of health service delivery. We believe that the model could be readily adapted to other districts or to other chronic conditions, such as heart failure or diabetes, for which evidence-based guidelines are available.

The model has provided a useful framework around which to base funding submissions and service planning discussion.


Abramson, M. et al (2001) Prevalence of COPD among middle aged and older adults. Respirology; S: A12.

Anderson, J. et al (2001) Literature Review of Integrated Bed and Patient Management. Melbourne: Monash Institute of Public Health.

Brown, A., Caplin, G. (1997) A post-acute respiratory outreach service. Australian Journal of Advanced Nursing; 14: 4, 5-11.

Ferraro, E. et al (2001) Impact of a hospital-based home care program on the management of COPD patients receiving long-term oxygen therapy. Chest; 119: 364-369.

Fortin, M. et al(2005) Prevalence of multi-morbidity among adults seen in family practice. Annals of Family Medicine; 3: 223-228.

Hernandez, C. et al (2003) Home hospitalisation of exacerbated COPD patients. European Respiratory Journal; 21: 58-67.

McKenzie, D.K. et al (2003) The COPDX Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease, Medical Journal of Australia; 178: 6l, S1-S40.

National Public Health Partnership (2001) Preventing Chronic Disease: A Strategic Framework. Background paper.

NICE (2004) Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. London: NICE.

Pauwels, R. A. et al(2001) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization global initiative for chronic obstructive lung disease (GOLD) executive summary. Respir Care. 2001;46:798-825.

Poole, P. et al (2001) Case management may reduce LOS in patients with recurrent admission for COPD. Respirology; 6: 37-42.

QueenslandHealth (2006) Queensland Strategy for Chronic Disease 2005-2015.

Thrall, J. (2005) Prevalence and costs of chronic illness in a health care system structure for treatment of acute illness. Radiology; 235: 1, 9-12.

Wagner, E.H. (1998) Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice; 1: 2-4.

Wilson, D. et al (2002) COPD prevalence in South Australia. American Journal of Respiratory and Critical Care Medicine; 165: 8, A55.

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