1) |
Respiratory and palliative care offered together, to provide individualised care which addresses the underlying respiratory disease, symptoms and psychosocial issues |
2) |
Disease treatment optimisation including: optimising inhaler therapy and device technique, smoking cessation support, pulmonary rehabilitation referral, and domiciliary oxygen therapy assessment, education and management |
3) |
Comprehensive management of refractory breathlessness, with nonpharmacological strategies (such as breathing techniques, recovery breathing positions, the use of a handheld fan) and opioids as required; individualised written breathlessness plans and written breathlessness resources provided |
4) |
Self-management support including patient and family education regarding disease and symptom management, with provision of written exacerbation action plans |
5) |
Routine discussions regarding goals of care and advance care planning |
6) |
Patient- and family-focused care including extended 1-h consultations, urgent reviews and rapid access (<1 week) for new referrals as needed |
7) |
Specific carer support including facilitating access to respite care and bereavement support |
8) |
Long-term follow-up with continuity of care in clinic and nonabandonment |
9) |
Telephone support and home visits provided by a respiratory nurse consultant |
10) |
Early access to “Hospital in the Home” care to avoid respiratory admissions |
11) |
Respiratory care and service coordination, and integration with other community services, including aged care assessment services |
12) |
Focus on early communication with, and support of, general practitioners and other health professionals, including teleconferences |