1. 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

2. 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

3. 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