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Integrating COPD care

How to improve quality and productivity by integrating COPD care. This latest case study from IMPRESS is a synthesis of current evidence and policy, illustrated by our report on North Tyneside, part of Northumbria Healthcare NHS Foundation Trust, one of two national (England) integrated care pilots focusing on people with COPD at risk of admission.

It highlights:

  • The bundle of activities that are needed: care planning, allocation of a key/named worker, routine measurement and feedback to primary care, robust patient assessment and referral to key services such as pulmonary rehabilitation, education and support for patients and professionals, and recording and provision of consistent information across primary and secondary care
  • How investment in relationships over time pays dividends and how much can be achieved outside the commissioning system, by providers alone
  • How general practice, supported appropriately by hospital specialists and social care specialists and working in a culture of trust can drive system change for the benefit of patients
  • It describes the potential for social care services such as support for carers and community alarm services as well as home support to be better integrated into care pathways to support patients
  • It makes the case for a consistent care approach to other long term conditions, particularly heart disease and diabetes, and for regular medication review

Finally, it demonstrates four sorts of integration: centred on an individual irrespective of long term condition(s), between primary and secondary care decision-making, between general practice and community nursing and between health and social care.  It includes current policy references and also reports from organisations such as the Nuffield and Kings Fund.