Health services and clinicians can use these clinical priorities, models and resources to deliver best-practice care for people with chronic obstructive pulmonary disease.
Chronic obstructive pulmonary disease (COPD) is a chronic, progressive condition with exacerbating features that limits airflow in the lungs. COPD has a high incidence of multimorbidity and can be complex, disabling and negatively impact on quality of life.
These resources were originally developed as one of the 13 clinical initiatives of Leading Better Value Care, a program accelerating value-based healthcare in NSW. They aim to:
- reduce unwarranted clinical variation
- increase education, resources and support for COPD patients to self-manage their disease
- develop optimal care after discharge and at end of life.
Snapshot of chronic obstructive pulmonary disease in NSW
- In 2024-25, 66 hospitals admitted more than 50 patients as a principal diagnosis.
- In NSW, there were 18,476 separations with COPD as principal diagnosis with an average length of stay of 5.5, accounting for 101,618 bed days.
Model of care
3Ci model of care 2023
Organisational model of care to improve outcomes and reduce unnecessary hospitalisations for people with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in NSW.
Guideline
The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease
Evidence-based guideline that shifts the emphasis from pharmacological treatment to a range of interventions including patient education, self-management of exacerbations and pulmonary rehabilitation.
Standard
The Chronic Obstructive Pulmonary Disease Clinical Care Standard
This Standard supports clinicians and healthcare services in delivering high-quality care for people with COPD. It includes ten quality statements that outline safe, appropriate care, along with indicators to help monitor performance and drive continuous improvement.
For clinicians and services
What to improve
A summary of the four clinical components of the initiative:
- Diagnosis
- Exacerbation management
- Optimising health through ongoing care
- Last year of life
How to improve
Explore options for different organisational models to tailor clinical services for your local requirements:
- Respiratory coordinated care program
- Nurse-led models of care
- Virtual health model
Case studies
- Pulmonary rehabilitation – a clinician's perspective (SESLHD)
- COPD outreach services – a clinician's perspective (NBMLHD)
- Integrated pulmonary rehabilitation – a clinician's perspective (SLHD)
- Inpatient liaison service and rapid access – a clinician's perspective (CCLHD)
- Respiratory coordinated care program – a clinician's perspective (ISLHD)
- Integrated COPD and CHF services – cardiorespiratory team – a clinician's perspective (SNSWLHD)
Additional resources
- Lung Foundation Australia, COPD Action Plan
- Lung Foundation, Pulmonary Rehabilitation toolkit
- EnableNSW Home Respiratory Program
- Non-Invasive Ventilation for Patients with Acute Respiratory Failure, Clinical Practice Guide
- Palliative Care Network, The Blueprint for Improvement
- Thoracic Society of Australia and New Zealand Clinical Practice Guideline on Adult Home Oxygen Therapy
- Thoracic Society of Australia and New Zealand Spirometry Suite of Documents for Australian Primary Care
- Monitoring and evaluation plan
Contact us
Email the team at ACI-Respiratory@health.nsw.gov.au