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Poster Abstracts

Caring Together 2 Breathe Easy: an integrated care trial to reduce readmission and improve the health care experience for people with COPD


Wayne George Middleton ,

Caboolture Hospital, AU
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Donna Ward,

Caboolture Hospital, AU
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Simon Finnigan,

Caboolture Hospital, AU
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John Adie,

Morayfield Family Doctors, AU
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Chrissie Norton

Morayfield Family Doctors, AU
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Introduction: As evidenced in  “Perils of Place – Identifying hotspots of health inequality” (Duckett, 2016), Caboolture (Queensland) was highlighted as having a 10 year history of higher than average readmission rates for patients with Chronic Obstructive Pulmonary Disease (COPD).

A new Integrated Pathway of Care is being trialled for COPD patients (n=30).  Key collaborators include:  the Caboolture Hospital Emergency Department and Respiratory Service; GP practices, Queensland Ambulance Service and key community services.

The model of care, known as Caring Together 2 Breathe Easy was developed in collaboration with Canterbury Health in New Zealand. This model employs a patient focus to improve QoL by implementing COPD Action Plans and ensuring that the patient, their GP, Ambulance and the Emergency Department utilise this plan, including  alternatives for acute care. 

A “Breathe Easy” team: GPLO, Clinical Nurse;  Physiotherapist and Psychologist,  work with the participants to implement action and intervention plans.  Participants are provided with a  pack which includes their COPD action plan, contact plan and educational materials.

Aims and Measures:

Reduced ED presentations  and re-admission rate within 28 days

Improved QoL measured by COPD Assessment Tool (CAT) and meeting individual goals

Identification of secondary anxiety and depression (K-10) and linkage to supports

Improved GOLD Score

Increased access and connection to health and community services

Developing integrated pathways with health and community services.

Targeted Population and Stakeholders: Patients with a diagnosis of COPD and a history of re-presentations and/or re-admissions to the Caboolture Hospital within 28 day within the past two years (N=30)

Participants reside in the Caboolture community which has recognised unmet health needs and high levels of socioeconomic disadvantage  (Source: The Social Health of Australia: Data by population area, Population Health Information Data Unit 2016)

Timeline 2017:

Feb: Cohort selected

March- April: Recruitment, Assessments

May-Jun: Action Plans

July-October: Interventions

Nov-Dec: Evaluation


COPD Action Plans developed for all patients;

High levels of consumer engagement with Breathe Easy Team and Project;

Interventions commenced;

Improved engagement and co-operation across secondary hospital, primary care, ambulance and community agencies.

Sustainability: The intention is to upscale and embed the “Breathe Easy” pathway trial at an organisational and local community level.

Transferability: If successful, the “Breathe Easy” trial outcomes will contribute to models of integrated care that can be applied to a range of patient groups requiring integrated care.

Conclusions: Caboolture Hospital “Breathe Easy” project is demonstrating high levels of engagement and support from consumers, health care providers and the community.  The multi-level evaluation data will provide evidence and inform viability for up-scaling and consolidation as an alternative health care service model in Caboolture and more broadly in Metro North HHS.

How to Cite: Middleton WG, Ward D, Finnigan S, Adie J, Norton C. Caring Together 2 Breathe Easy: an integrated care trial to reduce readmission and improve the health care experience for people with COPD. International Journal of Integrated Care. 2018;18(s1):131. DOI:
Published on 12 Mar 2018.


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