This project is delivering personalised care and support for people with COPD who require support to improve in their ability to self-manage. The integrated COPD service is identified patients who would benefit from personalised care planning through the PAM. Specialist COPD nurses are delivering personalised care, interventions and goals to improve the patient’s ability to self-manage.
The aim is to improve the patient’s level of activation, and reduce reliance on NHS services through improved self- management of their condition. This is being achieved by identifying the COPD patient population who would benefit from personalised care planning through the Patient Activation (PAM) or who had had frequent hospital admissions or attendance of pulmonary rehabilitation programme (High impact service users). Patients identified receive personalised support through specialist COPD nurses with skills in motivational interviewing and person centred care. The specialist nurses provide tailored small goals combined with focused interventions and support in home, clinic or in the community.
The service is using the Patient Activation Measure (PAM) a 13 question survey which measures a patient’s knowledge, skills and confidence to self-manage. The average improvement in patient PAM scores who have received personalised care planning is 7 points. According to the PAM scoring this shows a likelihood of 14% reduction in hospitalisation for these patients.
Enhancing and tailoring care planning to a more person led approach in patients with lower activation can improve a patient’s ability to manage their condition. This requires clinicians to focus on what matters to the patients and support the patients with small easily achievable goals. To deliver personalised care planning takes time and is emotionally challenging, but is effective in improving a patient ability to self-manage their condition. Patients who are able to self manage have better health outcomes and use healthcare services less for people with long term conditions.
