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Conference Abstracts

Enhancing integrated care for people living with chronic obstructive pulmonary disease (COPD) in a regional Victorian setting.

Authors:

Kristen Glenister ,

University of Melbourne, Department of Rural Health, Wangaratta, VIC, AU
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Tessa Archbold,

Northeast Health, Wangaratta, Victoria, AU
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David Kidd,

Northeast Health, Wangaratta, Victoria, AU
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Rebecca Disler

University of Melbourne, Department of Rural Health, Wangaratta, VIC, AU
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Abstract

Potentially avoidable hospitalisation (PAH) rates for chronic conditions may be decreased by improved integrated care. This project was initiated in response to high rates of PAH and emergency department (ED) presentations for chronic obstructive pulmonary disease (COPD) to a sub-regional hospital.

PAH for COPD were assessed using hospital admission, ED presentation, and GP utilisation data. Patients who had been recently hospitalised with COPD completed a survey and interview regarding barriers and enablers to navigating the healthcare system and living well with COPD. Health professionals completed a survey regarding barriers and enablers to providing integrated care in the region. A reference group comprising of 18 people including health professionals, consumers, researchers and the Murray Primary Health Network met monthly.

The key challenges identified included gaps in coordination of care, difficulties during transition of care and inter-agency communication. The insights from the reference group informed strategies to address these challenges, namely a Transition Officer position and a patient controlled booklet. The strategies were implemented and evaluated from the perspectives of both patients and health professionals. At baseline 95 patients had been admitted over 12 months for COPD, 52 patients (55%) had repeat admissions (up to 6). 81 patients had presented to ED during this period, 25 (31%) on multiple occasions (up to 8). After 12 months, 101 patients were admitted over 12 months, 36 (36%) on multiple occasions (up to 5). ED presentations (75) and repeat presentations (10, 13%) had decreased, although other factors may have also contributed to these results. After hours GP services had decreased over the same time period.

Patients (n=38) provided feedback about the strategies. Of the 9 respondents who had seen the Transition Officer, 8-9 had received information about their condition, discharge process, post discharge appointments, medication and help at home. Of the 18 patients who had received a booklet, over half said that it had made a ‘very helpful difference’ in understanding their breathing difficulties, medications and exacerbation management. Health Professionals (n=28) provided feedback about the Transition Officer position (clear, consistent point of contact during discharge and more efficient referral processes) and the booklet (valuable tool to assist self-management).

The key barriers to integrated care were similar to those reported previously. The strategies described here are in keeping with recognised benefits of partnerships, engagement, communication and shared medical information.

The strategies described were designed to improve both communication between health professionals and integrated care, particularly during transitions of care. The strategies have shown promising results for patients in this regional Victorian setting, although more time and increased engagement with the strategies may be required to observe reductions in PAH. The Transition Officer has initiated several key improvements to complex care coordination and referrals have increased.

The inclusion of multiple, complementary data sources and high level of engagement of the multidisciplinary reference group were invaluable aspects of this project.

Small sample sizes and single clinical site limit the generalisability of findings.

Future research involves inclusion of a neighbouring rural hospital and contined monitoring of COPD PAH patterns.

How to Cite: Glenister K, Archbold T, Kidd D, Disler R. Enhancing integrated care for people living with chronic obstructive pulmonary disease (COPD) in a regional Victorian setting.. International Journal of Integrated Care. 2021;20(S1):119. DOI: http://doi.org/10.5334/ijic.s4119
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Published on 26 Feb 2021.

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