Caring Together 2 Breathe Easy: an integrated care trial to reduce readmission and improve the health care experience for people with COPD

Abstract

Introduction: As evidenced in “Perils of Place – Identifying hotspots of health inequality” (Duckett, 2016), Caboolture (Queensland) was highlighted as having a 10 year history of higher than average readmission rates for patients with Chronic Obstructive Pulmonary Disease (COPD). A new Integrated Pathway of Care is being trialled for COPD patients (n=30). Key collaborators include: the Caboolture Hospital Emergency Department and Respiratory Service; GP practices, Queensland Ambulance Service and key community services. The model of care, known as Caring Together 2 Breathe Easy was developed in collaboration with Canterbury Health in New Zealand. This model employs a patient focus to improve QoL by implementing COPD Action Plans and ensuring that the patient, their GP, Ambulance and the Emergency Department utilise this plan, including alternatives for acute care. A “Breathe Easy” team: GPLO, Clinical Nurse; Physiotherapist and Psychologist, work with the participants to implement action and intervention plans. Participants are provided with a pack which includes their COPD action plan, contact plan and educational materials. Aims and Measures: Reduced ED presentations and re-admission rate within 28 days Improved QoL measured by COPD Assessment Tool (CAT) and meeting individual goals Identification of secondary anxiety and depression (K-10) and linkage to supports Improved GOLD Score Increased access and connection to health and community services Developing integrated pathways with health and community services. Targeted Population and Stakeholders: Patients with a diagnosis of COPD and a history of re-presentations and/or re-admissions to the Caboolture Hospital within 28 day within the past two years (N=30) Participants reside in the Caboolture community which has recognised unmet health needs and high levels of socioeconomic disadvantage (Source: The Social Health of Australia: Data by population area, Population Health Information Data Unit 2016) Timeline 2017: Feb: Cohort selected March- April: Recruitment, Assessments May-Jun: Action Plans July-October: Interventions Nov-Dec: Evaluation Highlights: COPD Action Plans developed for all patients; High levels of consumer engagement with Breathe Easy Team and Project; Interventions commenced; Improved engagement and co-operation across secondary hospital, primary care, ambulance and community agencies. Sustainability: The intention is to upscale and embed the “Breathe Easy” pathway trial at an organisational and local community level. Transferability: If successful, the “Breathe Easy” trial outcomes will contribute to models of integrated care that can be applied to a range of patient groups requiring integrated care. Conclusions: Caboolture Hospital “Breathe Easy” project is demonstrating high levels of engagement and support from consumers, health care providers and the community. The multi-level evaluation data will provide evidence and inform viability for up-scaling and consolidation as an alternative health care service model in Caboolture and more broadly in Metro North HHS.