Chronic Obstructive Pulmonary Disease (COPD): best practice guide

5. Sub group and key themes

The Working Group divided into sub-groups, each tasked with exploring a different theme in relation to improving the care of COPD patients. The themes were:

• Reducing ED Attendances and hospital admissions/readmissions: This subgroup focused on exploring all initiatives that supported safe home management for patients with stable disease or whose exacerbation could be managed in the pre-hospital environment. In the larger conurbations (Edinburgh and Glasgow) the presence of a Community Respiratory Team ( CRT) facilitated this and made it possible, however the group acknowledged the geographical variation across Scotland and was also tasked with looking at alternative models of care where no CRT existed. The emphasis was also very clearly on pulmonary rehabilitation ( PR) which has been demonstrated to reduce the frequency of exacerbations, strengthen exercise tolerance and improve overall patient wellbeing ( https://www.blf.org.uk/support-for-you/exercise/pulmonary-rehabilitation).
• Scottish Ambulance Service ( SAS): As mentioned above the SAS 2020 vision of 'Taking Care to the Patient' was at the heart of the group's ambitions for shifting the balance of care to the home environment so it was decided to have a separate subgroup dedicated to SAS initiatives. The focus was on building stronger links with the SAS and ensuring they have access to Key Information Summaries ( KIS) and an awareness of alternatives to admission for COPD patients.
• NHS 24 and Telehealth: This subgroup considered IT-based solutions, such as 'Skyping' patients, 111, SMS communications between specialists and patients, and other technology solutions that offered bespoke alternatives to 999 and secondary care. Leads looked at streamlining patient pathways and tests of change that strengthened the linkage between NHS 24 and CRT-like services, but also focused on how call handlers at NHS 24 might identify patients with COPD or emphysema, prompting them to access the patient's Anticipatory Care Plan. The aim was to ensure that more patients receive care that is bespoke and right for them.
• Anticipatory Care Planning, Pharmacy initiatives and Palliative care: The focus of this subgroup was again to engender a bespoke approach to patient care, but especially for those whose condition was terminal. From the pharmacy viewpoint the focus was on development of the community pharmacist role, not solely for acute management, but through its potential to integrate with other services.