The primary focus of the C2C Project will be to share information between primary, community and hospital service providers so that patients will be appropriately established in their chronic disease care, and are given the best options possible for maintenance and exacerbation management. This should lead to a reduction in Emergency Department presentations, Hospital admission and readmissions.
The key strategies to support these outcomes are:
- Establishing a phone line for patient support to be staffed by nursing
- Establishing a phone line for GP support and to facilitate direct admission, which will be staffed by nursing and doctors
- Identification of patients with COPD with an Action Plan and without and Action Plan
- Proactive development of COPD Action Plans and a proactive approach to prevention and maintenance with specific strategies for each of smoking cessation, pulmonary rehabilitation, spirometry, flu vaccination and airway clearance
- Notification of Queensland Ambulance Service of Action Plans in households
- Upskilling of staff in primary and community care, Emergency Department and Wards regarding best practice care
- Bolstering Pulmonary Rehabilitation in Caboolture
- Bolstering nursing, medical, psychology and physiotherapy resources in the hospital
