The aim for the initiative is that a discrete population of patients with COPD are managed with a different model of care such that they incur lower costs and enjoy better health outcomes. Changes to the model of care should be acceptable to providers and patients and factors that hindered and promoted adoption should be revealed so the innovation can be implemented successfully and sustained with fidelity in other settings.
Chronic Obstructive Pulmonary Disease (COPD)
Summary
Aim
Implement sustainable practices to improve disease screening and diagnosis for patients with or at risk of COPD.
Benefits
- Primary care screening and case identification improvement
- Post hospital rehabilitation access and care planning improvement
Background
COPD is a progressive long-term disease of the lungs that causes shortness of breath. It is prevalent among populations in Metro North and when poorly managed is likely to incur greater cost and worse mental and physical health. Current management of these patients in MN HHS could be improved and evidence based practice is:
- early disease identification, to slow progression
- appropriate therapy using a stepped approach based on disease severity
- patient-centred care plans in partnership with a health professionals and other carers
- early intervention to reduce the severity of exacerbations
- access to pulmonary rehabilitation, particularly following an exacerbation
The challenge for health services is to implement these by working with general practices, PHN leadership, the Lung Foundation and primary care services. There is a need to improve early identification and diagnosis of patients with COPD in a primary care setting, and then proactively plan for care and optimise management of the condition in primary care.
The Integrated Care Innovation Fund provides financial support to innovative projects that deliver better integration of care, address fragmentation in services and provide high-value healthcare. Funded projects also demonstrate a willingness to embrace and encourage the uptake of new technology alongside the benefits of integrating care and improving communication between health care sectors.