COPD Outreach Programme: Model of Care

Objectives

The Chronic Obstructive Pulmonary Disease (COPD) Outreach Service is a patient-centred, evidence-based chronic disease management model designed to bridge hospital and community care. It prioritises early supported discharge for selected patients with uncomplicated acute exacerbations of COPD, while helping patients manage symptoms, prevent deterioration and exacerbations, improve quality of life and maintain independent functioning.[1][2][3][4]

• Provide early supported discharge, ordinarily within 72 hours of presentation where acute inpatient care would otherwise be required, and assisted discharge where patients remain in hospital longer but meet the service scope.[4][5]
• Reduce COPD admissions, emergency department presentations, inappropriate admissions, length of stay, repeat admissions and re-exacerbations, while increasing bed availability.[4][6][7]
• Support patients and carers to recognise early deterioration, follow individualised self-management and care plans, use medicines and inhalers correctly, and access appropriate treatment and follow-up.[3][8]
• Promote smoking cessation, vaccination, exercise, airway clearance, pulmonary rehabilitation, coping strategies and social functioning.[4][8][7]
• Ensure diagnosis and clinical decisions are informed by assessment, including spirometry-confirmed COPD diagnosis where appropriate, disease stage and comorbidities.[1][3]
• Integrate pulmonary rehabilitation as an individualised multidisciplinary intervention intended to reduce symptoms, improve functional status, participation, exercise capacity, breathlessness, fatigue and health-related quality of life, and reduce healthcare utilisation.[7][9]
• Extend services according to local need to include assisted discharge, prevention of readmission, non-invasive ventilation, home oxygen support, pulmonary rehabilitation, in-reach and respiratory outpatient activity.[7]

Implementation

Care is delivered through multidisciplinary COPD Outreach Teams operating across hospital and community settings, using Hospital at Home and supported-discharge pathways for clinically suitable patients. Local hospitals are responsible for implementation and resourcing, while clinical teams work with respiratory physicians, general practitioners, hospital services, community providers, patients, families and relevant statutory, voluntary, education and professional organisations.[10][2][11][12][13]

• Assess eligibility against agreed inclusion and exclusion criteria, including COPD diagnosis, clinical stability, cognitive capacity, telephone access, social support and patient consent; exclude patients with specified acute clinical conditions, inadequate home support or needs incompatible with home management.[5]
• Conduct comprehensive hospital assessment covering COPD history and severity, spirometry, arterial blood gases, observations, investigations, smoking and vaccination status, social circumstances, symptoms, quality of life, treatment adherence and inhaler technique.[5]
• Plan individualised hospital-to-home packages that provide prescribed treatment, clinical review, education, nebuliser support where needed, oxygen assessment, airway-clearance advice, tailored exercise, vaccination and smoking-cessation support, respiratory passports, self-management plans and referral to community services.[8]
• Visit patients daily during the first three days at home, followed by reviews at two and six weeks; other assisted-discharge arrangements include contact within 24 hours, assessment within one week and return to general practitioner care after two to three visits where appropriate.[8][14]
• Maintain respiratory consultant clinical responsibility for the first two weeks after discharge, inform the general practitioner after the first home visit, and provide a detailed discharge summary when outreach visits are complete.[11][8]
• Provide a deterioration pathway through patient contact arrangements, liaison with respiratory teams, emergency outpatient review or referral, and hospital readmission through the emergency department when required; establish local out-of-hours and weekend arrangements.[8]
• Resource the proposed team with respiratory nursing, senior respiratory physiotherapy, clerical support and respiratory clinical expertise, although the wider document recognises that local staffing and resource needs may vary.[11][13]
• Embed local governance within existing organisational structures, with defined accountabilities and reporting lines to hospital management or the chief executive officer. Hold quarterly multidisciplinary reviews of progress, benefits plans, risks and performance targets.[13]
• Require hospital management to undertake quarterly service reviews and report performance to the Health Service Executive Chronic Pulmonary Disease Collaborative Programme, while teams maintain patient records, manage risks and follow programme policies, procedures, guidelines and protocols.[13]
• Maintain patient databases and reporting systems covering referrals, assessments, acceptance and non-acceptance, visits, discharge types, admissions, length of stay, readmissions, quality of life and disease impact.[5][15][16]
• Report centrally after the first year and then every six months using agreed statistics, key performance indicators and benefits plans; establish local baselines and targets and validate relevant admission data against the Hospital In-Patient Enquiry system.[4][11]
• Measure outcomes through audit and research, including re-admission and re-exacerbation rates, length of stay, dyspnoea, spirometry, quality of life and pulmonary rehabilitation exercise outcomes.[2][3][9][14]
• Use national targets that included a 20% reduction in admissions in 2012, a one-day reduction in average length of stay in 2012, a two-day reduction in 2013, and maintenance of readmission rates at 30–40%, alongside locally defined quality-of-life and disease-impact targets.[4]

Monitoring & Evaluation

Monitoring combines central performance reporting, local patient-level databases, clinical audit and outcome measurement for Chronic Obstructive Pulmonary Disease (COPD) Outreach Services. Local baseline data and targets are to be established before implementation, with admission data validated against the Hospital In-Patient Enquiry (HIPE) system.[4]

• Report agreed statistics, key performance indicators and a benefits plan to the National COPD Programme after the first year and every six months thereafter.[4]
• Track admissions, average length of stay, readmissions, re-exacerbations, emergency department presentations, referrals, assessments, home visits, patient visits, discharges, bed availability, treatment adherence, quality of life and disease impact.[4][6][7][16]
• Apply national targets of a 20% reduction in admissions in 2012, a one-day reduction in average length of stay in 2012, a two-day reduction in 2013, and maintenance of readmissions at 30–40%; set local targets for quality of life and disease impact.[4]
• Use HIPE diagnostic codes J40–J47 for people aged over 35 years to assess admissions, discharges and length of stay, while recognising that HIPE may misclassify COPD and does not capture the full outreach caseload.[11]
• Maintain a COPD Outreach database and reporting template recording patients reviewed, assessed, accepted or not accepted, reasons for non-acceptance, visit information, clinical assessments, vital signs, breathlessness, disease impact, quality of life and responses to treatment.[11][5][8]
• Assess outcomes through readmission and re-exacerbation rates, length of stay, dyspnoea scores, quality of life and spirometry. Randomised Hospital at Home studies reported an average 10% reduction in readmissions compared with controls.[2][3]
• Use validated measures including the modified Medical Research Council measure for disease impact, the incremental shuttle walk test, six-minute walk test, Hospital Anxiety and Depression Scale, Chronic Respiratory Disease Questionnaire, St George’s Respiratory Questionnaire, EQ-5D and COPD Assessment Test.[11][17][15]
• Interpret incremental shuttle walk test improvements of 47.5 metres as a small clinically significant benefit and 78.7 metres as a greater benefit; interpret a four-unit St George’s Respiratory Questionnaire change and a two-point COPD Assessment Test change as clinically significant thresholds.[14][17][15]
• Maintain monthly statistics by referral or service setting, including total assessments and discharge categories for early discharge, assisted discharge, outpatient discharge and readmission-prevention activity.[15]
• Review progress, service impact and benefits-plan targets quarterly through multidisciplinary meetings; require clinical teams to report quarterly to hospital management, and hospital management to report to the Health Service Executive Chronic Pulmonary Disease Collaborative Programme.[13]
• Conduct continuous audit, research and evaluation to improve care models, disseminate good practice and adapt interventions to individual patient outcomes.[12][6][7][9]

The indicator framework includes fields for baseline, actual performance, target, variance, reasons for variance and comments, although the extract does not provide completed baseline or actual values.[16]The supplied material does not specify a comprehensive national surveillance system, a universal audit schedule or full external accountability arrangements beyond the reporting and governance mechanisms described.[3][9][14]

Costing & Financing

The material presents COPD Outreach and Hospital at Home as potentially cost-effective alternatives to inpatient care, but it does not set out a national programme budget, financing plan, funding gap, costing methodology or resource-mobilisation mechanism.[2][3][4][11]

• Report international hospitalisation costs of 32 billion United States dollars in the United States in 2000, 500 million pounds in the United Kingdom in 2002, and 8.8 billion Australian dollars in Australia in 2008.[18]
• Report average Irish inpatient costs of 6,212 euros per COPD admission in 2006, with 11,000 admissions costing 68,332,000 euros in total, a 13% increase compared with 2004.[18]
• Recognise additional cost pressures from primary care, medication non-adherence and long-term oxygen therapy; worldwide waste and excess costs associated with non-compliance in chronic diseases were estimated at up to, or more than, 300 billion dollars annually.[18]
• Estimate that assisted discharge could enable one in five COPD admissions to be managed at home, reduce average length of stay by two days within two years and reduce admissions by approximately 20% annually.[6]
• Report urban outreach financial savings of 1,148,547 euros from 879 bed days for 134 patients in 2008 and 1,179,382 euros from 1,160 bed days for 136 patients in 2009.[7]
• Identify savings associated with early discharge, assisted discharge, prevented readmissions, outpatient discharge and pulmonary rehabilitation.[6][7]
• Note that local services must determine applicable capital and non-pay costs, as recurring cost items may vary between settings.[13]
• Require greater strategic planning and financial commitment from stakeholders and financial controllers for nationwide expansion.[6]
• Recognise that EQ-5D licensing fees may apply, with charges determined by study type, funding source, sample size and requested languages; no fee amounts are provided.[17][15]

The outreach model is described as requiring minimal physical resources and typically two to three staff, although proposed service staffing also includes a respiratory nurse, senior respiratory physiotherapist and 0.5 whole-time-equivalent clerical administrator.[6][11]No monetary valuation is provided for these resource inputs, medicines, nebulisers, oxygen assessment or referred community services.[8]