Skip to main content

Table 1 Components of a community-based respiratory service and their associated model elements, adapted from Wagner’s Chronic Care Model *

From: Development of a community-based model for respiratory care services

Model Elements Components
Community resources and policy Links with community services and resources
Self-management support Carer and family support
Patient behaviour-change interventions, e.g. pulmonary rehabilitation
Self-management support strategies
Delivery system design Regular patient follow-up
Care provided by a multi-disciplinary team
Integration of care between primary and secondary sectors
Integrating palliative care into the community
Decision Support Evidence based guidelines
Involving specialists to improve the care delivered by the team
Continuing professional development and advanced training for the team
Clinical information systems Individual patient care/treatment plans
Disease registers of COPD patients
Performance monitoring of the COPD team
  Identifying relevant subgroups of patients for care
  1. *sourced from Improving Chronic Illness Care [37, 38].