X3.8 Support after discharge

Follow-up at home after discharge from hospital may extend the continuum-of-care process begun within the acute envi­ronment, although evidence supporting benefit from nurse-led chronic disease management for people with COPD is absent (Taylor et al., 2005) [evidence level I]. Telephone follow-up may be a way of systematically extending support to patients and increasing their coping strategies at home, but the outcomes of this intervention have not been studied systematically.

An integrated approach involving a discharge plan shared with the primary care team together with access to a case manager through a web-based call centre has been shown to reduce re-admissions for COPD exacerbations compared to usual care (Casas et al., 2006) (evidence level II). This trial was conducted in Europe and the applicability to other settings is not known.