Key care element | At-risk | Group A | Group B | Group C | Group D | In exacerbation | Key care element administered by |
Low risk, less symptoms | Low risk, more symptoms | High risk, less symptoms | High risk, more symptoms | ||||
1. Smoking prevention | ✓ | Doctor, case manager, pharmacist | |||||
2. Smoking cessation | ✓ | ✓ | ✓ | ✓ | ✓ | Doctor, case manager, pharmacist | |
3. Differential diagnosis | ✓ | Doctor, case manager | |||||
4. Spirometric diagnosis | ✓ | 18–24 monthly or when clinician suspects patient grouping has changed | Doctor, case manager, spirometry technologist | ||||
5. Patient education | ✓ | ✓ | ✓ | ✓ | Doctor, case manager, pharmacist | ||
6. Drug optimisation | ✓ | ✓ | ✓ | ✓ | ✓ | Doctor, case manager, pharmacist | |
7. Influenza vaccination (yearly) | Only for elderly (≥65 years) and those who have concomitant | ✓ | ✓ | ✓ | Doctor, case manager | ||
8. Body mass index assessment (yearly) | ✓ | ✓ | ✓ | ✓ | Doctor, case manager, physiotherapist | ||
9. COPD assessment tool | 6–12 monthly | 6–12 monthly | 6–12 monthly | 3–4 monthly | Doctor, case manager, ICP coordinator, physiotherapist | ||
10. Acute non-invasive ventilation | ✓ | Doctor, case manager | |||||
11. Supported restructured hospital/emergency department discharge | ✓ | Doctor, case manager, ICP coordinator, medical social worker | |||||
12. Home oxygen | ✓ | ✓ | Doctor, case manager | ||||
13. Advance care planning | ✓ | ✓ | Doctor, case manager, medical social worker |