6. The Vision for Optimal COPD Care
Drawing on the above workstreams the COPD Working Group distilled the ideal COPD patient pathway into the following acronym:
e Exacerbation Management - Local initiatives and protocols
C Community Respiratory Team - This could be approached creatively in those regions that don't have a CRT where paramedic practitioners or other healthcare professionals might be deployed
O Online and Offline Support - e.g. 'Florence' (an SMS-based text messaging service that allows patients to relay information on their clinical observations to a specialist in real time), COPD websites, technology-enabled care
P Pulmonary Rehabilitation - Including the use of leisure facilities, peer groups, choirs etc. that give the individual a good 'lung workout'
D Documentation of an Anticipatory Care Plan ( ACP) in the Key Information Summary ( KIS), which clearly outlines the patient's physical, psychological and social needs, resuscitation status and level of escalation during an acute exacerbation.
Email: Syed Kerbalai
Phone: 0300 244 4000 – Central Enquiry Unit
The Scottish Government
St Andrew's House