Reducing hospital readmissions with GP appointments for long-term conditions patients

A free appointment for COPD patients provides greater support following hospital discharge and aims to reduce readmissions.

WellSouth primary health network is this week launching a fully-funded GP appointment for patients with Chronic Obstructive Pulmonary Disease being discharged from hospital. This appointment supports patients moving from hospital-based care to general practice, helping them to stay well at home, with care provided by the general practice, rehabilitation and other community-based services.

“We know that seeing a general practice team soon after hospital discharge increases compliance with a care plan and significantly reduces the likelihood of re-admission,” says Katrina Braxton, WellSouth Clinical Services Manager. “For patients it means more certainty. They have a GP appointment booked within 14 days of leaving hospital, ensuring they get the support they need from the health providers who know them best.”

COPD is a disease affecting the lungs and airways, causing breathing difficulties. Most often caused by smoking, COPD is among the most common long-term conditions in New Zealand, impacting 200,000 New Zealanders, including 15% of people over 45 years old.

Booking a GP appointment is also now part of Southern DHB’s respiratory and internal medicine services discharge process. This checklist is used to ensure patients receive referrals and advice for correct medicine and inhaler use, pulmonary rehabilitation options, and information about smoking cessation, healthy homes, and advance care planning.

“The funded GP appointment and other steps on the discharge checklist are simple but effective for improving health and preventing hospital readmission,” says Dr Jack Dummer, Southern DHB respiratory specialist, who was part of team to have developed a COPD discharge checklist. “A lot of ED presentations and hospital admissions for COPD are preventable. We want to help patients to manage their conditions and encourage them to get the care they need outside of hospital.”

Complements other COPD initiatives
The COPD post-discharge appointment is the latest step by WellSouth to deliver more comprehensive and connected respiratory care for COPD patients in the community.

Other initiatives include an ambulance diversion programme, in partnership with St John. Ambulances attending calls from COPD patients can arrange treatment at a general practice, if appropriate, rather than taking the individual to ED. WellSouth’s Blue Card programme, is a summary of all care plan information on a single A5 card. This card provides key steps to help people with COPD to stay healthy at home, including advice on when to call for assistance.

Ms Braxton says patients can find it easier to follow medical instructions when in hospital, but once discharged, day-to-day life can get in the way, so extra support at this time can be particularly helpful.

“These COPD initiatives are what we mean when we talk about integrated care,” says Ms Braxton. “It is the health system working together, with the patient and their practice, to provide the right care, at the right time and by the right health care provider.”