The South East Essex model for Integrated COPD care: A collaborative scheme involving PCT, Hospital, Community Service, General Practice, University and Breathe Easy

Abstract

South East Essex PCT has commissioned an integrated COPD service. At the core is the philosophy of patient centered care to achieve high quality care, equality of care for all patients with COPD, ease of access so patients receive the appropriate care, producing an educational programme which ensures a sustainable service, improved patient information and patient involvement. The aims are also to reduce hospital follow up attendances and hospital admissions. This service has been planned through the local COPD network group where all stakeholders are involved. It was agreed that the Respiratory Consultants would provide clinical leadership for the whole COPD service across boundaries. The network has developed guidelines for managing COPD, a self-management plan and patient pathway. The agreed patient pathway is particularly important in developing the philosophy of the service. A manager has taken on the role of Project manager. The job plans of the Respiratory Consultants have changed and they have started doing clinics in the community. Two thirds of the clinics are conventional and the other thirds are multidisciplinary clinics where staff (usually Community Matrons) bring cases to be discussed without the patients having to attend. This arrangement is outside of tariff and operates through a contract variation. Both these initiatives have moved care closer to home. Community Matrons see many of the patients with severe COPD at home, protocols have been agreed as to whether patients remain on the active case load. Integrated services include the hospital at home service. This is both a prevention of admission and early discharge scheme service.