Table 3 TEAMcare patients’ structured management plans
Participant | Individualised management plan |
|---|---|
Participant 2 (ACOS) | Initial Further assessment: glycaemic status, osteoporosis Goal: weight loss, symptom control 5 months Identified: impaired glycaemic control, dyslipidaemia Assessment: suboptimal symptom control Plan: change inh (device and regimen), repeat RFT, reconfirm lipid and glycaemic results, commence Resp HEAL |
Participant 3 (COPD, OSA, T2DM, CRF, CCF) | Initial Goal: weight loss, recommence CPAP 5 months Assessment: deterioration in heart failure (addressed by cardiologist) Identified: elevated scores for anxiety and depression, suboptimal glycaemic control and dyslipidaemia (on treatment), stably impaired renal function Plan: further assessment/referral for anxiety and depression, reassess treatment for diabetes (dyslipidaemia within acceptable limits), extend duration of supplemental oxygen from nocturnal to 24 h/day, recommence CPAP, broach advanced directives/end of life care plan, check Pneumococcal vaccination status 10 months Assessment: Improved physically/psychologically, using CPAP Plan: change inh (drug), update COPD action plan, reconcile medications (GP), check Pneumococcal vaccination status |
Participants 4 (ACOS, OSA, T2DM) | Initial Goal: weight loss Plan: improve inh adherence 5 months Identified: deterioration in anxiety, Plan: correct inh technique, further assessment of anxiety 10 months Plan: change inh regimen (drug and device), refer to psychologist (GP) |
Participant 7 COPD, emphysema | Initial Goals: smoking cessation Further assessment: osteoporosis, glycaemic control Plan: NRT for smoking cessation, further assessment anxiety/depression 5 months Successfully quit smoking, anxiety/depression scores improved Plan: change inh regimen (drug and device), BMD scan, ENT review if dysphonia continues |
Participant 8 COPD, ABPA, OSA, T2DM | Initial Further assessment: osteoporosis Goal: weight loss, symptom control Plan: check anti-pneumococcal antibodies 5 months Identified: osteopaenia, suboptimal glycaemic control, dyslipidaemia Plan: change inh regimen (drug), reassess lipids and glycaemic control post exercise programme, endocrinology review |
Participant 11 COPD, OSA, | Initial Goal: weight loss, recommence/maintain CPAP Further assessment: osteoporosis Plan: monitor hypertension 5 months Identified: renal impairment Assessment: hypertension controlled with new antihypertensive Plan: commence Resp HEAL, adjust inh (reduce dose) |
Participant 12 COPD | Initial Goal: weight loss Plan: change inh (drug and device), influenza and Pneumococcal vaccination, cardiology review 5 months Identified: resumed smoking, depressive symptoms, poor inhaler technique Plan: smoking cessation, further assessment of depression, change inh (drug and device) |