None listed
Conditions
Brief summary
The aim of this project is to pilot the implementation of care coordination plus early rehabilitation in a high-risk COPD population in transition from hospital to primary care. This intervention will dovetail with the existing Sub-Acute Respiratory Services (SRS) of the Central Adelaide Local Health Network (CALHN) and the Central Adelaide and Hills Medicare Local (CAHML) COPD Project. Stronger partnerships will be created to improve the clinical handover of patients and address gaps identified by both services. This study will determine whether this model of care coordination plus early rehabilitation is feasible, acceptable, carried out with fidelity and effectiveness (compared with a no-intervention control group). If so, this model could be implemented in a larger Australian cluster randomised trial and outcomes examined over a longer duration. If effective, the role of specialist Nurse Practitioners as community care coordinators could be implemented as effective links between primary and acute hospital care of people with chronic lung conditions. Study Hypotheses (a) Implementation of the pilot intervention (care coordination plus early rehabilitation) is feasible, satisfactory to patients and carers and can be delivered with fidelity. (b) Care coordination plus early rehabilitation will result in (i) documentation of agreed patient goals and (ii) demonstrated progress toward them assessed by the four major Flinders Program Care Planning Tools: Partners in Health / Cue and Response / Problems and Goals assessment and Self-Management Plan in at least 85% of cases. (c) Care coordination plus early rehabilitation will involve collaboration with the patient's GP/practice nurse with generation of a Team Care Arrangement in at least 85% of cases. (d) People with COPD who participate in care coordination plus early rehabilitation will have lower hospital readmission rates at 28 days and greater physical activity levels at 28 days after discharge than a control group of similar patients.
Interventions
The care coordination plus early rehabilitation intervention (flexible duration 1-2 months depending on patient needs) will be implemented by a specialist respiratory Nurse Practitioner (NP) and a research assistant physiotherapist (RPT) and include the following components:
(1) Liaison with existing Sub-acute Respiratory Service (SRS) inpatient hospital COPD coordinator for streamlined transition into SRS.
(2) Care coordination by weekly home visit (NP) to patient (30 min- 1 hour each week duri
The care coordination plus early rehabilitation intervention (flexible duration 1-2 months depending on patient needs) will be implemented by a specialist respiratory Nurse Practitioner (NP) and a research assistant physiotherapist (RPT) and include the following components: (1) Liaison with existing Sub-acute Respiratory Service (SRS) inpatient hospital COPD coordinator for streamlined transition into SRS. (2) Care coordination by weekly home visit (NP) to patient (30 min- 1 hour each week during 1-2 month intervention) with additional phone contact as required, including the following components: Needs assessment, problem identification, goal setting and care planning with the patient (using the Flinders Program). The patient’s carer will be invited to participate in care planning discussions. Facilitation of referrals across all health sectors in collaboration with the patient/carer and relevant members of the health care teams involved. (3) Early rehabilitation by weekly visit (research assistant physiotherapist; 30 min visits weekly during 1-2 month intervention) including the following components: Walking program: commence at 2 x10 min walks/day prescribed at 40% of peak speed in 2 minute walk test prior to hospital discharge; optimal walking aid prescription Interrupt daytime sedentary periods of >1 hour with sit-stand. Use of self-report exercise diary. (4) Collaboration with patient/carer, local primary care practice nurse and GP to integrate care using existing MBS items (Team Care Arrangement/Case Conference).
Sponsors
Dr Kylie Johnston
Study design
Allocation
Non-randomised trial
Primary purpose
Treatment
Eligibility
Sex/Gender
All
Age
40 Years to 100 Years
Healthy volunteers
No
Inclusion criteria
Patients admitted to hospital with a primary diagnosis of COPD; confirmation of COPD diagnosis by previous pulmonary function testing; length of admission at least 48 hours.
Exclusion criteria
Potential participants are excluded if they have (a) insufficient English language or cognition to give informed consent; (b) been unable to walk during the previous 3 months.
Outcome results
None listed