Chronic Obstructive Pulmonary Disease (COPD): best practice guide

6. The Vision for Optimal COPD Care

Drawing on the above workstreams the COPD Working Group distilled the ideal COPD patient pathway into the following acronym:

e Exacerbation Management - Local initiatives and protocols

C Community Respiratory Team - This could be approached creatively in those regions that don't have a CRT where paramedic practitioners or other healthcare professionals might be deployed

O Online and Offline Support - e.g. 'Florence' (an SMS-based text messaging service that allows patients to relay information on their clinical observations to a specialist in real time), COPD websites, technology-enabled care

P Pulmonary Rehabilitation - Including the use of leisure facilities, peer groups, choirs etc. that give the individual a good 'lung workout'

D Documentation of an Anticipatory Care Plan ( ACP) in the Key Information Summary ( KIS), which clearly outlines the patient's physical, psychological and social needs, resuscitation status and level of escalation during an acute exacerbation.