Table 5 Model of community-based respiratory services
From: Development of a community-based model for respiratory care services
| Â | Type of consensus met | Component | Standard to which component should be met | Level of priority |
|---|---|---|---|---|
Original components | General | Integrating care between primary and secondary sectors | A high priority and all chronic disease interventions include active coordination between primary care, specialists and other relevant groups. | High |
| Â | Â | Performance monitoring of the COPD team | Is timely, specific to the team, routine and personally delivered by a respected opinion leader to improve team performance. | High |
| Â | Â | Individual patient care/treatment plans | Established collaboratively and include self management as well as clinical management. Follow-up occurs and guides care at every point of service. | High |
| Â | Full | Continuing professional development and advanced training for the team | Include training in all practice teams in chronic illness care methods such as population-based management, and self-management support. | High |
| Â | Â | Integrating palliative care into the community | N/A | High |
| Â | Â | Links with community services and resources | Actively sought to develop formal supportive programs in order and policies across the entire system. | High |
| Â | Â | Carer and family support | An integral part of care and includes systematic assessment and routine involvement in peer support, groups or mentoring programs. | High |
| Â | Â | Self-management support strategies | Provided by trained clinical educators who are designed to do self-management support, affiliated with each practice, and who see patients on referral. | High |
| Â | Pure | Evidence based guidelines | Available, supported by provider education and integrated into care through reminders and other proven provider behaviour | High |
| Â | Â | Care provided by a multi-disciplinary team | Assured by regular team meetings to address guidelines, roles and accountability, and problems in chronic illness care. | High |
| Â | Â | Disease registers of COPD patients | Tied to guidelines which provide prompts and reminders about needed services. | High |
| Â | Â | Patient behaviour-change interventions, e.g. pulmonary rehabilitation | Readily available and an integral part of routine care. | High |
Additional components | General | Acute exacerbation | N/A | High |
| Â | Full | Smoking cessation | N/A | High |
| Â | Â | End-of-life care | N/A | High |
| Â | Â | Long-term oxygen therapy | N/A | High |