COPD Pathway Admitted to ward with exacerbation Av

COPD Pathway Admitted to ward with exacerbation Av 70/month A&E With exacerbation Av 100/month GP/LTC referral for Severe COPD only S/B MTW RNS on ward S/B RNS in A&E S/B RNS in community COPD Plan of care (see below) RNS review at home ESD via ERR’s Complex cases Frequent attenders MDM (10 new Or 8 new 4 FU) Exercise recovery programme Onward referral HOT Consultant Clinic 4 pts/week Medicine User Review Pulmonary Rehab Smoking cessation GP LTC O 2 assessment Palliative Care

COPD plan of care Assessed for: • Smoke stop referral • PR referral • Inhaler regime and technique • Early Supported Discharge (ESD) (hospitalised patients) • Review by MDM • Home oxygen assessment Offered: • Follow up visit by Nurse or 72 hour phone follow up • Post exacerbation exercise recovery programme at home Given: • Anticipatory care plan • Self management plan • Written inhaler technique information • Oxygen alert card (if appropriate) • Team contact numbers

MDM Scope • Patients within West Kent with COPD, who are identified as having complex needs, or who have had 2 or more exacerbations of their COPD requiring a hospital admission Aim • Ensure accurate diagnosis • Optimise treatment • Refer appropriately to other specialisms/palliative care team • Ensure fully supported in community to self manage their condition Referral • Via MDM coordinator Membership • Core members : consultant/ MTW respiratory nurse/ MDM coordinator/KCHT Respiratory team member/LTC nurse • Additional members: Palliative Care, Health and Social Care, SECAMB, OT, pharmacy, heart failure nurses - as required