Table 5.

Model of community-based respiratory services

	Type of consensus met	Component	Standard to which component should be met	Level of priority
Original components	General	Integrating care between primary and secondary sectors	A high priority and all chronic disease interventions include active coordination between primary care, specialists and other relevant groups.	High
		Performance monitoring of the COPD team	Is timely, specific to the team, routine and personally delivered by a respected opinion leader to improve team performance.	High
		Individual patient care/treatment plans	Established collaboratively and include self management as well as clinical management. Follow-up occurs and guides care at every point of service.	High
	Full	Continuing professional development and advanced training for the team	Include training in all practice teams in chronic illness care methods such as population-based management, and self-management support.	High
		Integrating palliative care into the community	N/A	High
		Links with community services and resources	Actively sought to develop formal supportive programs in order and policies across the entire system.	High
		Carer and family support	An integral part of care and includes systematic assessment and routine involvement in peer support, groups or mentoring programs.	High
		Self-management support strategies	Provided by trained clinical educators who are designed to do self-management support, affiliated with each practice, and who see patients on referral.	High
	Pure	Evidence based guidelines	Available, supported by provider education and integrated into care through reminders and other proven provider behaviour	High
		Care provided by a multi-disciplinary team	Assured by regular team meetings to address guidelines, roles and accountability, and problems in chronic illness care.	High
		Disease registers of COPD patients	Tied to guidelines which provide prompts and reminders about needed services.	High
		Patient behaviour-change interventions, e.g. pulmonary rehabilitation	Readily available and an integral part of routine care.	High
Additional components	General	Acute exacerbation	N/A	High
	Full	Smoking cessation	N/A	High
		End-of-life care	N/A	High
		Long-term oxygen therapy	N/A	High

N/A - not available.