1. Blueprint COPD Services (1/2) 1 Health and Wellbeing Self and Informal Care New Primary Care  New anti-smoking campaign, well-coordinated and consistent across all health and social care providers  Identification of people with risk factors for COPD and referral to GP for screening  Patient support groups for smoking cessation and for coping with COPD  Self-monitoring for FEV1 and state of respiratory health and level of functioning  Self-starting Abx and steroids for exacerbations  Relaxation (meditation, behavioural therapy methods) to reduce anxiety  Patients (and carers) are part of care planning and have access to care plan (incl. workflow plan)  Telemetry is available where remote monitoring enables greater independence  Friends & family support for patients for daily living  Local voluntary organisations are part of the support network  Supported housing and domiciliary care (where necessary) reflects the needs of COPD patients  Proactive case seeking for people with risk factors and screening  Proactive risk monitoring and early intervention  Enhanced smoking cessation courses (with psychol. support) to achieve higher long- term quit rates  Repeated pulmonary rehab (ideal frequency to be agreed)f  Patient education, incl. focus on inhaler technique  24/7 availability to respond to urgent patient calls  Rapid access to telephone advice by competent clinician who has access to patient records and care plans  Complex cases are discussed and advised in MDTs with specialists  Complex cases have a named lead clinician who is in charge of coordinating all care and who is the main point of contact for the patient EXAMPLE

2. Blueprint COPD Services (2/2) 2 Mobile Clinical Services Urgent Transfer New Secondary Care System Enablers  Immediate response to patients with shortness of breath – assessment treatment attempt by mobile clinician with relaxation, nebulisers, oxygen if needed  24/7 ability to check with NPC about baseline level of patient status – conveyance only if status worse and initial treatment not working after adequate trial time  MCS aware of all available service alternatives at any given time to help patient select preferred route of further care, when needed  To A&E for respiratory distress only  To GP practice in hours  Potentially transfer to intermediate care beds in community after assessment by GP, or Mobile Clinician  Consultant expertise available to advise NPC without referral for urgent calls and for regular MTD sessions were complex, high risk cases can be discussed  Diagnostics (imaging and spirometry) available by direct access and in community outposts  Hospital clinicians have immediate access to up-to-date clinical records and care plans from New Primary Care  OPD can directly refer to smoking cessation and pulmonary rehab  NELIP services discharge patients with discharge package that focuses on secondary prevention  Discharge preparations from hospital involve New Primary Care to ensure seamless care  In-hospital services for patients with multiple LTCs are well coordinated  Reimbursement by YOC tariff to a lead provider (ICO?)  Formation of an organisational entity for New Primary Care (ICO?)  Improved information flows through better IT system links EXAMPLE