About the COPDnet modelWe have designed an innovative care model for people suffering from a chronic respiratory disorder such as asthma or COPD, who require an integrated diagnostic process.
What does the COPDnet model look like?The COPDnet model consists of an integrated diagnostic process for secondary care. Depending on the complexity of a case, intervention can then be offered with primary, secondary or tertiary care.
The COPDnet model was created for patients who have been referred to secondary care for medical specialist care and is based on a stepped care model. Patients with a moderate or severe disease burden, who have insufficient success in improving their situation with primary care, are eligible for referral. After referral by the family doctor, patients will follow a relatively short, standardized stepped diagnostic process with secondary care, aimed at analysis of the patient's integrated health status and initiating self-management.
Individual care planThis process involves drawing up an individual care plan in close consultation with the care givers (lung specialist and specialized lung nurse) and the patient. The starting point is empowerment for self-management. Depending on the complexity of the support required in an individual case, the plan may be implemented within primary care, secondary care or a referral will be made to a tertiary-carespecialized lung convalescence program. However, in most cases, the patient will be referred back to primary care. Allied healthcare professional may be involved in the implementation of the individual care plan. If the care is transferred back to primary care, the family doctor and nurse practitioner will be responsible for monitoring progress. A state-of-the-art, modular intervention program for non-pharmacological treatment was developed for allied healthcare professionals working within primary care. The model encompasses systematic recording of the results achieved at several moments and for different aspects of the patient's health status, using both process and outcome indicators. Among other things, this recording is used as part of a quality management system to provide feedback to care givers about the outcome of the care. The objective is to obtain a learning organization form.
Care close to homeThe starting point of the COPDnet model is that care should be given as close to the patient's home and living environment as possible. It is of vital importance that the various care givers in the different care echelons (primary, secondary and tertiary) have laid down sound regional collaboration agreements. This includes agreements about referral criteria and back referral criteria, but also about exacerbation management and palliative care.
Example caseMr. Jansen is 57, works in security and his family doctor has diagnosed him with moderate COPD (gold 2). Lately, he has consulted the family doctor several times due to increasing shortness of breath and fatigue complaints. Medication changes by the family doctor resulted in little improvement, upon which the doctor proposed referring Mr. Jansen to the outpatient's clinic for pulmonary diseases for advice. At the clinic, an integrated analysis of his health status was conducted. Mr. Jansen's medical state and also his physical activity, psychosocial factors and quality of life were mapped out. Various points for improvement of his health status were identified: stop smoking cigarettes, optimization of his medication inhalation technique and become less overweight and more active in daily life. The lung specialist and lung nurses discussed with Mr. Jansen which goals he would like to reach and which aspect he would like to work on. It was jointly decided that he would start becoming more active in his daily life. Mr. Jansen was referred to an occupational therapist specialized in COPD for this purpose. The family doctor was also informed about the results of the integrated analysis. The doctor was also asked to further support Mr. Jansen. The remaining treatment options can be started step by step by the family doctor and nurse practitioner at a later date.
Why the COPDnet model?
Why the COPDnet model?
The care for people with COPD should be and can be improved. Within this context, it is important to tailor the care to the individual patient. It is also important to organize the care optimally. Different care givers contribute to the care for patients with a chronic respiratory disorder, e.g. the family doctor, nurse practitioner, lung specialist, specialist nurse and various paramedics. This means that the care must be fine-tuned, which sets high requirements with regard to communication and clarity for the patient.
Application of the COPDnet model should lead to more effective, transparent care and contribute to the efficient use of care. By continuing to develop the COPDnet model, the Pulmonary Diseases Department takes on its academic responsibilities for people with a chronic respiratory disorder, such as asthma or COPD.