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 |