Trial of nurse and GP partnership for care of COPD

Intervention Practices This structured 6-month intervention involves GP and COPD management nurse working together to provide care for patients with COPD. Standardised training for the COPD Management Nurses to develop specialised skills in COPD management will be provided by the study team under direction of professor Guy Marks (Chief investigator C) who is Director of Respiratory Medicine at Liverpool Hospital with input from respiratory specialist liaison nurses at Liverpool and Fairfield Hospitals. Intervention process The COPD Management Nurse will work with the GP, the patients and other care providers. Patients will receive two home visits and five telephone contacts from the nurse and a minimum of two consultations with their GP over a six-month period. The nurse and GP will meet face to face on two occasions and further consultation between the nurse and GP will take place by telephone monthly or more frequently when needed to discuss progress and problems. Nurse role: 1. 1st Home visit The nurse will assess the patient, confirm the diagnosis and evaluate severity, assess smoking and immunisation status, assess the patient’s understanding of their condition and management. During this visit, the nurse will identify specific management issues for the patient and provide standardised education. 2. Care plan preparation and implementation The nurse will initiate preparation of the care plan tailored to the patient’s needs and based on the COPDX guidelines. The nurse will meet with the patient’s GP to discuss the care plan and organise an appointment for the patient with the GP for completion of the plan. The nurse will work with the GP and other health professionals to implement the plan. The nurse will organise an appointment for the patient at 4 months for review with the GP. 3. 2nd home visit During this consultation the nurse will review the patient’s understanding of the care plan, motivation and progress on implementation of each element of the plan. 4. Telephone calls The nurse will proactively telephone the patient fortnightly after the 1st home visit and monthly after the 2nd home visit to check understanding, motivate uptake of the plan and address barriers to implementation of each element of the plan. 5. Hand-over of care At six months the nurse will provide a written report on implementation of the plan for the GP and patient and handover care to the GP and other members of the care team. GP role: 1. Care plan preparation and implementation The GP will meet with the nurse to discuss the care plan and then have a consultation with the patient to finalise the plan. Copies of the completed plan will be provided by the GP to the patient, the nurse and other health professionals involved in the patient’s care. The GP will see the patient to implement aspects of the care plan eg medication management, immunisation. GP visits will vary depending on individual patient needs. 2. Review At four months the GP will review management of the patient. Care plan content: The care plan will be based on the recommendations of the COPDX evidence-based guidelines. The plan will seek to optimise management, improve function, prevent deterioration and enhance patient knowledge and skills. he care plan will be individualised to the needs of the patient and contain relevant components of the following: 1. Smoking cessation: recommended management will be based on Smoking Cessation Guidelines for Australian General Practice. Prof Nicholas Zwar, Chief Investigator A (CIA), led the development of these guidelines. 2. Immunisation: Influenza and pneumococcal vaccination status will be assessed. If vaccination is required, the patient will be referred to the GP for this to be done. 3. Pulmonary rehabilitation: Patients with moderate or severe COPD will be referred to a pulmonary rehabilitation program in Sydney South West Area Health Service which incorporates exercise and education. 4. Medication review: This will involve the nurse, GP and/or pharmacist. The review will involve a check of symptom control, compliance, optimising the use of short and long acting bronchodilators and inhaled corticosteroids, education about medications and assessment of and education about inhaler technique. 5. Nutrition: Patients with Body Mass Index outside the health weight range will be identified. Management will include nurse and/or GP advice about diet and exercise and referral to a dietician. 6. Psychosocial issues: Patients with known anxiety and/or depression will be assisted by the nurse to access counselling by the GP, referral to a psychologist or psychiatrist and medication. 7. Patient education: Patients will be provided with written information about COPD and its management. Patients will also be provided with information about local patient support groups (Lung Savers Group) which provide emotional support and enhance education provided by health professionals. 8. Co-morbidities and complications of COPD: Patients with co-morbidities and complications such as pulmonary hypertension, sleep apnoea and right heart failure will be referred for specialist assessment where the GP and nurse identify that further investigation and management are needed.