COPD Pathway MDM (10new Or 8new 4 FU) Admitted to ward with exacerbation Av 70/month A&E With exacerbation Av 100/month GP/LTC referral for Severe COPD only Complex cases Frequent attenders S/B MTW RNS on ward S/B RNS in A&E S/B RNS in community COPD Plan of care (see below) MDM (10new Or 8new 4 FU) ESD via ERR’s RNS review at home Exercise recovery programme Onward referral HOT Consultant Clinic 4pts/week COP Medicine User Review Pulmonary Rehab Smoking cessation GP LTC O2 assessment Palliative Care

COPD plan of care Assessed for: Smoke stop referral PR referral Inhaler regime and technique Early Supported Discharge (ESD) (hospitalised patients) Review by MDM Home oxygen assessment Offered: Follow up visit by Nurse or 72hour phone follow up Post exacerbation exercise recovery programme at home Given: Anticipatory care plan Self management plan Written inhaler technique information Oxygen alert card (if appropriate) Team contact numbers

MDM Scope Patients within West Kent with COPD, who are identified as having complex needs, or who have had 2 or more exacerbations of their COPD requiring a hospital admission Aim Ensure accurate diagnosis Optimise treatment Refer appropriately to other specialisms/palliative care team Ensure fully supported in community to self manage their condition Referral Via MDM coordinator Membership Core members : consultant/ MTW respiratory nurse/ MDM coordinator/KCHT Respiratory team member/LTC nurse Additional members: Palliative Care, Health and Social Care, SECAMB, OT, pharmacy, heart failure nurses - as required