An Integrated Model for Community COPD Care

Abstract

Chronic obstructive pulmonary disease (COPD) represents one of the main causes of morbidity and mortality in the western world. Acute exacerbations of COPD were a major cause of hospital admissions and emergency department attendances and represented a considerable economic burden on health resources in the Northern Sydney Area Health Service of Sydney, NSW. To redress deficits in access and equity in health care delivery and to align with best practice, the Area Health Service implemented a comprehensive, interagency, multidisciplinary model of care for chronic respiratory disease in the community setting. The BREATHE program provides nursing, physiotherapy, occupational therapy, clinical psychology, pharmacy and community care aid services in a client's home at a flexible level according to their acuity and complexity of health care needs. This program works in collaboration with primary care providers to provide specialty respiratory services not previously available. Since commencement of client intake in 2001, the program has observed reductions in health care utilisation and improvement in health outcomes.