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New End to End COPD Model of Care from the National Clinical Programme

The published model of care for COPD sets out a route map to provide more comprehensive and appropriate care for patients with COPD.

Published: 24 January 2020

The published model of care for COPD sets out a route map to provide more comprehensive and appropriate care for patients with COPD.

This will not only set out a more effective use of resources but allow patients to have a better quality of life and a more prolonged life.

Chronic obstructive pulmonary disease (COPD) is a disease of the lungs characterised by airflow obstruction. This airflow obstruction is usually progressive and partially reversible. The disease is associated with increasing breathlessness and in more severe cases can be associated with exacerbations of the disease, which may necessitate intervention either in general practice, attendance at the hospital or even admission. Tobacco smoking is the most important risk factor for the development of COPD

COPD has a considerable impact on the quality of life of the patient, families and carers, involving on-going medical care, frequent hospital admissions for treatment of exacerbations and often resulting in premature death. Ireland has the highest rate of hospital admission with COPD of any country in the OECD. The frequency, severity and complexity of COPD is obvious and it is estimated that 500,000 people are living with COPD in Ireland– only 200,000 of these are diagnosed

There is a disparity in the availability of services throughout the health service. The care delivered to patients is not standardised which can result in poor outcomes for patients. The National Clinical Programme (NCP) for COPD are working to shape the future of COPD care in Ireland. The group is working under the guidance and support of the Chronic Disease Team including Dr Orlaith O’ Reilly and Mairead Gleeson.

The NCP for COPD plans and directs the delivery of care to people with COPD.

Their key aims are:

  • to prevent or delay the onset of COPD
  • to improve the delivery of care to people with COPD across all levels of care
  • to save the lives of people with COPD

This Model of Care for COPD defines the way health services for people with COPD should be delivered. The document outlines the best practice integrated care and services for a person with, or at risk of developing, COPD as they progress through the stages of their condition.

The Model of Care for COPD reflects the full spectrum of care and service provided in hospitals and in the community for people with COPD.

The spectrum of services, ranging from primary prevention to tertiary care, includes:

  • Primary prevention and health promotion
  • Risk factor identification and management
  • Early detection of disease and diagnosis
  • Secondary prevention
  • GP led Primary care management of disease
  • Shared primary and secondary care management of disease
  • Secondary care management of chronic disease
  • Tertiary care

The 2019 End to End Model of care for COPD includes:

(i) The management of COPD

  • disease prevention
  • early assessment and diagnosis
  • management of established COPD
  • management of an exacerbation of COPD
  • management of comorbidities in COPD
  • care and support for advanced COPD

(ii) Epidemiology, prevalence, costs & trends in hospitalisation

(iii) Tools for use including self-management tools and acute care and discharge bundles

The model takes a holistic, person centred and life course approach to the provision of services. It reflects the principles of integrated care; to provide patients with the right care at the right time by the right team in the right place.

The actions outlined in the Sláintecare Implementation Strategy are reflected in the model.

The launch was supported by Minister Catherine Byrne, Laura Magahy, Sláintecare, Dr. Orlaith O’Reilly, Prof JJ Gilmartin from COPD Support Ireland and our patient representative Michael Drohan.