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Table 3 TEAMcare patients’ structured management plans

From: Implementation challenges in delivering team-based care (‘TEAMcare’) for patients with chronic obstructive pulmonary disease in a public hospital setting: a mixed methods approach

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)
  1. Legend: ACOS asthma/COPD overlap syndrome, OSA obstructive sleep apnoea, T2DM type II diabetes mellitus, CRF, chronic renal failure, CCF congestive cardiac failure, ABPA allergic bronchopulmonary aspergillosis, inh inhaled treatment, RFT respiratory function tests, Resp HEAL respiratory HEAL programme, CPAP continuous positive airways pressure, NRT nicotine replacement therapy, BMD bone mineral density, ENT ear, nose and throat (surgeon)