Guidelines:

Guidelines such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for COPD and the Global Initiative for Asthma (GINA) provide standardised recommendations for diagnosis and treatment.

https://ginasthma.org

https://goldcopd.org

NICE Guidelines for COPD

https://www.hse.ie/eng/about/who/cspd/ncps/ncpr/copd/ncec-guideline-management-of-copd.pdf

NICE guidelines for Asthma:

https://www.nice.org.uk/guidance/ng80

PPPGs (Patient Pathway Planning Guides:

Attached is a step-by-step guide outlining the expected pathway for patients with COPD and Asthma. This covers the respiratory assessment, treatment plans, and follow-up procedures such as spirometry and Feno.

Websites:

1.     www.asthma.ie

2.     www.wehale.ie

3.     www.copd.ie

4.     https://www.copdfoundation.org/Learn-More/I-am-New-to-COPD/Breathing-Techniques.aspx

5.     https://www.brit-thoracic.org.uk

Patient Information Booklets, Passports, Information & Booklets

Lots of booklets and self-management care plans on Asthma and COPD care from websites like :

www.healthpromotion.ie

Asthma action plan: https://www.asthma.ie/sites/default/files/files/document_bank/2023/Oct/ASI%20-%20Asthma%20Action%20Plan%202022.pdf

Asthma resources:

https://www.asthma.ie/about-asthma/resources

COPD and Me information booklet

https://copd.ie/wp-content/uploads/2021/10/COPD-Me-Booklet-2021.pdf

COPD communication Card

https://www.hse.ie/eng/about/who/cspd/ncps/ncpr/copd/resources/copd-communication-card.pdf

COPD Self-Management Plan

https://www.hse.ie/eng/about/who/cspd/ncps/ncpr/copd/resources/copd-self-care-plan.pdf

Planning a future with COPD

https://hospicefoundation.ie/wp-content/uploads/2021/01/COPD-Information-Booklet-Feb-2018.pdf

Sing strong: Singing for better lung health: SingStrong@copd.ie.

Smoking cessation:

https://copd.ie/living-well-with-copd/smoking-cessation/

APPs

Mobile applications have been developed for patient education, medication reminders, and communication with healthcare professionals.

MyCOPD app: Contents an activity diary that enables patients to track and record their daily activities. It provides educational videos which include inhaler techniques and pulmonary rehab exercise programs.

My mhealth (Asthma): https://mymhealth.com/myasthma

This app is an online self-management app that helps patients achieve better control of their disease. It is equipped with educational videos and tracks symptoms.

Advicelines:

Asthma: 1800 44 54 64

COPD: 1800 83 21 46

Self-Care:

Respiratory patients must understand their condition, including triggers and signs of exacerbation. Education should include inhaler techniques, lifestyle modifications, and understanding when to seek medical attention.

Medication Management:

We realise polypharmacy can be an issue with many chronic disease management patients; that’s why it's essential to include information about correct usage and potential side effects of their medications. Adherence is so crucial when it comes to patients' medication and treatment.

Integrated Care:

Primary Care Team (PCT)

Usually, the patient's first point of contact is where initial diagnosis, management and regular check-ups occur—consistent monitoring, which includes blood and ECG, to recognise deterioration or symptoms of excavations. Once diagnosed, the patient is coded according to disease and commenced on the chronic disease program.

https://www.hse.ie/eng/about/who/gmscontracts/2019agreement/chronic-disease-management-programme/chronic-disease-management-gp-booklet.pdf

Acute Hospital Support:

For severe exacerbations of other complications of respiratory that made hospital care or treatment. Follow-up may be arranged to see a specialist respiratory consultant and may need advanced tests like pulmonary function tests, CT or Echocardiogram.

Community Support:

Integrated Care HUB:

Community integrated care teams, which include specialist nurses, physiotherapists, consultants and advanced nurse practitioners, care for unique patients with respiratory diseases that meet their criteria.

eHealth:

Electronic health records facilitate communication between various healthcare professionals, ensuring all the information is distributed to everyone involved in their care. An example of an eHealth service is Health Link.

Integrated care HUB:

In the integrated care hub, I met a group of respiratory nurse specialists conducting morning clinics and comprehensive assessments of patients with asthma and COPD. They consider physical, psychosocial, and environmental factors in their assessments.

They triage incoming referrals from general practitioners who come in via post or Healthlink. They can carry out procedures such as spirometry to view patients' lung function and tailor treatment around this. A lot of their role revolves around education and the prevention of exacerbations. They have a pulmonary rehabilitation centre on-site and can refer according to criteria. (see attached)

Treatment will depend on spirometry/feno/allergy/blood tests, which will be tailored to the patients. I talked about the guidelines in the post above. I've attached the current criteria for the respiratory integrated care HUB, and I managed to get information on how they assess their patients. Chest X-rays and echocardiograms aren't available and referred to the hospital, but this will be built into the HUB in the coming months.

It was lovely to meet you today & to discuss the SMILE project. Please find attached patient consent form, referral criteria and patient information leaflet.

Please share this information with the rest of the staff in the practice.

We look forward to receiving referrals from you now. Please contact me at the email above, or the SMILE service Smile@caredoc.ie with any queries

The SMILE 2 project centres on integrated virtual case management of patients with multi-morbid chronic disease in the community. It is a 2 year Slaintecare funded project between the HSE Enhanced Community Care programme and the chronic disease hubs partnering with Caredoc. The virtual case management is provided by trained triage nurses combined with remote patient monitoring, to support patients with multi-morbidity to live more independently and reduce their episodes of deterioration. We accept referrals from the Chronic Disease hubs, GP practices and acute services.

Additional information (recordings)

For more information on SMILE, please see the full 1 hour Slaintecare webinar (Nov 2023) about the SMILE project: https://vimeo.com/revolutionaries/review/880934168/c6fe299c1a

Click here to view Niamh-Ann, one of the SMILE nurses, talking about the kinds of patients that the SMILE nurses see in the service. This may support you when you are considering appropriateness of referrals https://youtu.be/ZpEzC0SSSx8?si=_T9N1womSiccP8TS&t=2592 (5 mins recording from Slaintecare webinar Nov 2023)

Please view the recording here with two participants talking about their experience of the service (6 mins recording from Slaintecare webinar Nov 2023)

RTE also featured the SMILE 1 project in 2020 with short video included https://www.rte.ie/news/2020/0925/1167409-slaintecare-health-smile/

Please don’t hesitate to contact me with any queries

Kind regards

Agatha

Agatha Lawless, Project Manager: SMILE 2

Integrated Virtual Case Management of Patients with Multimorbid Chronic Disease in the Community

Primary Care Strategy and Planning|HSE|Waterford Vaccination Centre|Ballytruckle Road|Waterford|X91 XFC9

Tel: 087 7988363 Email: agatha.lawless@hse.ie