Table 1

The chronic obstructive pulmonary disease integrated care pathway (COPD-ICP) programme key care elements

Key care elementAt-riskGroup AGroup BGroup CGroup DIn exacerbationKey care element administered by
Low risk, less symptomsLow risk, more symptomsHigh risk, less symptomsHigh risk, more symptoms
1. Smoking preventionDoctor, case manager, pharmacist
2. Smoking cessationDoctor, case manager, pharmacist
3. Differential diagnosisDoctor, case manager
4. Spirometric diagnosis18–24 monthly or when clinician suspects patient grouping has changedDoctor, case manager, spirometry technologist
5. Patient educationDoctor, case manager, pharmacist
6. Drug optimisationDoctor, case manager, pharmacist
7. Influenza vaccination (yearly)Only for elderly (≥65 years) and those who have concomitantDoctor, case manager
8. Body mass index assessment (yearly)Doctor, case manager, physiotherapist
9. COPD assessment tool6–12 monthly6–12 monthly6–12 monthly3–4 monthlyDoctor, case manager, ICP coordinator, physiotherapist
10. Acute non-invasive ventilationDoctor, case manager
11. Supported restructured hospital/emergency department dischargeDoctor, case manager, ICP coordinator, medical social worker
12. Home oxygenDoctor, case manager
13. Advance care
Doctor, case manager, medical social worker