• Run by the Hywel Dda Local Health Board.
  • Aimed at improving care for patients with chronic obstructive pulmonary disorder (COPD) and reducing unnecessary hospital admissions.
  • Looked at the whole care experience, cutting across acute, primary and community boundaries.
  • Specifically focused on discharge from hospital so patients would feel safe and well informed.

Patients with COPD live with a chronic condition that can flare up at certain times and cause a hospital admission. This project looked at the whole care experience to try and improve support for patients and reduce the need for hospital admissions.

The project had five main aims:

  • Engage health care professionals with the Patient and Family Centred Care methodology.
  • Enable patients to remain well and manage their condition with access to ongoing support.
  • Align services to the needs of patients and make them responsive to individual requirements.
  • Give patients access to 24/7 support and advice.
  • Provide an appropriate response in an emergency.

A multi-disciplinary team (covering primary, secondary and community health care as well as social care) implemented a number of measures that would help improve patient experience and reduce hospital admissions, including:

  • improving communications between primary and secondary care
  • agreed care plans and key workers for patients to ensure continuity and oversight of care
  • a minimum standard of agreed care for all patients with COPD (eg annual flu vaccination, and identifying barriers to receiving it)
  • a referral protocol for all patients with COPD to pulmonary rehab and/or a self-management programme
  • information and support for patients to manage their condition (including help self-checking symptoms using a sputum colour check card, better understanding of individual triggers and appropriate responses, telehealth and text messaging, ‘emergency packs’ including stand by antibiotics, and possible further support eg through a breathlessness clinic)
  • the ability to discharge direct from A&E with support
  • setting a maximum stay in hospital.

Further reading


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