D1. Support team

Clinical support teams working with the primary healthcare team can enhance quality of life and reduce disability for patients with COPD [evidence level III-2, weak recommendation]

Patients and their family and friends should be actively involved in a therapeutic partnership with a range of health professionals (Celli 1995, Spruit 2013, Ries 1995, Lorig 1999). In advanced disease, the many comorbidities, social isola­tion and disability mean that a multidisciplinary approach to coordinated care may be appropriate.  Studies have demonstrated the potential benefits of an interdisciplinary approach on patient quality of life, symptom control, exercise tolerance and hospital episodes (Chavannes 2009, Kruis 2014). Many different healthcare professionals are involved in the crucial components of COPD management, including case finding, smoking cessation support, pharmacotherapy, exercise training and self-management and education and exercise training. A program with an emphasis on co-operation and collaboration between these providers should be established for more effective patient care.  Multidisciplinary collaboration can improve the diagnosis and management of COPD in primary care. Structuring collaboration and communication between primary care professionals involved in the management of COPD (i.e. general practitioners (GP), nurses, physiotherapists, pharmacists and dieticians) is elementary to achieve this. Links should also be built between primary and secondary care in order to accomplish optimal multidisciplinary care for COPD patients (Schermer 2008).

The general practitioner plays a key role in the delivery and coordination of care for people with chronic disease including COPD and can access a range of Medicare items to support the delivery of multi-disciplinary care. The multidisciplinary team, depending on local resources, may include the mem­bers listed below. The role of respiratory specialists is outlined in section C: Case finding and confirm diagnosis.