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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].