Free GP follow-up for discharged COPD patients
A free appointment for COPD patients provides greater support following hospital discharge and aims to reduce re-admissions.
WellSouth primary health network is this month launching a fully-funded GP appointment for patients with Chronic Obstructive Pulmonary Disease being discharged from hospital. The programme supports patients moving from hospital-based care to general practice and helps them to stay well at home, with the help their general practice teams, rehabilitation and community-based services.
“We know that seeing a general practice team soon after hospital discharge increases compliance with a care plan and significantly reduces the likelihood of re-admission,” says Katrina Braxton, WellSouth Clinical Services Manager. “For patients it means more certainty. They have an appointment booked within 14 days of discharge, ensuring they get the support they need from the health providers who know them best.”
COPD is a disease affecting the lungs and airways, causing breathing difficulties. Most often caused by smoking, it is among the most common long-term conditions in New Zealand, impacting 200,000 New Zealanders, including 15% of people over 45 years old.
Booking a follow-up general practice appointment is now part of Southern DHB’s respiratory and internal medicine services discharge process – a checklist that also ensures patients receive referrals and advice for correct medicine and inhaler use, pulmonary rehabilitation options, and information about smoking cessation, healthy homes, and advance care planning.
“The funded GP appointment and other steps on the discharge checklist are simple but effective for improving health and preventing hospital readmission,” says Dr Jack Dummer, Southern DHB respiratory specialist, who was part of team to have developed a COPD discharge checklist. “A lot of ED presentations and hospital admissions for COPD are preventable and we want to help patients to manage their conditions and encourage them to get the care they need, outside of hospital.”
Complements other COPD initiatives
The COPD post discharge appointment is the latest step by WellSouth to deliver more comprehensive and connected respiratory care for COPD patients in the community.
Other initiatives include an ambulance diversion programme, in partnership with St John, whereby ambulances attending calls from COPD patients can arrange treatment at a general practice, if appropriate, rather than taking the individual to ED. WellSouth’s Blue Card programme, meanwhile, is a plan-on-a-page, providing key steps to help patients to stay healthy at home, including advice on when to call for assistance, and summarising all care plan information on a single, A-5 card that can be attached to a fridge door.
Ms Braxton says patients can find it easier to follow medical instructions when in hospital, but once discharged, day-to-day life can get in the way, so extra support at the time of discharge can be particularly helpful.
“These COPD initiatives are what we mean when we talk about integrated care,” says Ms Braxton. “It is the health system working together, with the patient and their practice, to provide the right care, at the right time and by the right health care provider.”