Case study: Outreach services
The following case study from Leah Calman, Nepean Blue Mountains LHD, provided a clinician's perspective on models of care from a local perspective.
What is important to know about your service?
Chronic Obstructive Pulmonary Disease (COPD) accounts for 4.9% of preventable hospitalisations in the Nepean Blue Mountains LHD and is the fourth leading cause of death. Nepean Hospital provides specialised COPD outreach services to care for, and support people, who live in the Penrith area.
What organisational model do you use?
Outreach services include:
- home visits
- phone consultations
- telehealth
- outpatient clinics.
Care is provided by a multidisciplinary team that includes medical, nursing and physiotherapy.
Diagnostic testing
Exacerbation management
Ongoing care
Last year of life
What is special about the way care is delivered?
The service offers a four-week, home-based pulmonary rehabilitation program for people with COPD. This is a stepping-stone program to cut the waiting time for formal pulmonary rehabilitation programs. It includes guided home exercises that optimise function, provide education and improve recovery. This is done in the comfort of the patient’s home.
The service offers a nurse-led COPD supportive care pathway for people with advanced disease or unstable symptoms. If required, patients can be reviewed by a palliative care specialist. Care includes the review and optimisation of symptoms, discussion and support for fears and concerns about death and dying, advanced care planning, goal setting to improve quality of life and support for families and carers.
Nepean Hospital has a multidisciplinary COPD out-patient clinic. It operates from 9am to noon once a week. The clinic is supported by a:
- respiratory doctor
- nurse
- supportive care nurse
- physiotherapist.
The aim of the clinic is to confirm diagnosis, optimise treatment, develop self-management plans, manage chronic symptoms, and provide support to improve patient confidence and quality of life.
A companion document describes options for organisational models in COPD. One option is outreach services – this vignette describes the model from a local perspective.
How does it make a difference?
Observing improved outcomes and improved quality of life for patients gives staff greater job satisfaction. It allows us to invest in what works well. Personalising care for patients and seeing outcomes of improved quality of life empowers us to continue to strive to meet the changing personal and complex health needs of people with COPD.
What tips do you have for others?
- Patients can remain under the care of the general practitioner with the supportive care model.
- Understand competing priorities or other programs that have different funding sources to prevent waste of service delivery and overlap of programs with the same goals.