Effect on Hospitalisation and Cost Effectiveness of a Respiratory Coordinated Care Program for patients with Chronic Obstructive Pulmonary Disease.

The intervention is a Respiratory Coordinated Care Program. This is a multidisciplinary program for chronic respiratory disease patients involving regular outpatient follow ups by nurse specialists with liaison with physiotherapists, occupational therapists, respiratory registrars and consultants. These visits involve one on one home visits, initially weekly, then fortnightly and then monthly at the discretion of the treating nurse and team. At each visit, the patient's clinical state is assessed, as well as compliance with treatment, equipment supply and patient understanding of proper usage e.g. inhaler and spacer technique, referral to pulmonary rehabilitation as needed, and recognition of early clinical deterioration prompting an action plan whereby the community nurse would directly contact a respiratory physician or senior registrar, and early community treatment such as antibiotics, bronchodilators and steroids could be implemented. The service also provides close follow up of patients post discharge from hospital in order to facilitate ongoing recovery from their illness, and allow more rapid discharge from hospital. Missed visits are followed up with phone calls.