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Table 5 Model of community-based respiratory services

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

  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
   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
   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
  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
   Integrating palliative care into the community N/A High
   Links with community services and resources Actively sought to develop formal supportive programs in order and policies across the entire system. High
   Carer and family support An integral part of care and includes systematic assessment and routine involvement in peer support, groups or mentoring programs. High
   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
  Pure Evidence based guidelines Available, supported by provider education and integrated into care through reminders and other proven provider behaviour High
   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
   Disease registers of COPD patients Tied to guidelines which provide prompts and reminders about needed services. High
   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
  Full Smoking cessation N/A High
   End-of-life care N/A High
   Long-term oxygen therapy N/A High
  1. N/A - not available.