Improving the COPD care experience Hywel Dda Local Health Board

Patients with COPD live with a chronic condition that can flare up at certain times and cause a hospital admission. This project looked at the whole care experience to try and improve support for patients and reduce the need for hospital admissions.

The project had five main aims:

• Engage health care professionals with the Patient and Family Centred Care methodology.
• Enable patients to remain well and manage their condition with access to ongoing support.
• Align services to the needs of patients and make them responsive to individual requirements.
• Give patients access to 24/7 support and advice.
• Provide an appropriate response in an emergency.

A multi-disciplinary team (covering primary, secondary and community health care as well as social care) implemented a number of measures that would help improve patient experience and reduce hospital admissions, including:

• improving communications between primary and secondary care
• agreed care plans and key workers for patients to ensure continuity and oversight of care
• a minimum standard of agreed care for all patients with COPD (eg annual flu vaccination, and identifying barriers to receiving it)
• a referral protocol for all patients with COPD to pulmonary rehab and/or a self-management programme
• information and support for patients to manage their condition (including help self-checking symptoms using a sputum colour check card, better understanding of individual triggers and appropriate responses, telehealth and text messaging, ‘emergency packs’ including stand by antibiotics, and possible further support eg through a breathlessness clinic)
• the ability to discharge direct from A&E with support
• setting a maximum stay in hospital.