Life with COPD a passport to better care

07 November 2018

Community matron Susan Nyandoro explains how a Devon trust is enhancing continuity of care for those with chronic lung disease.

copd Superstock

Chronic obstructive pulmonary disease (COPD) and its exacerbations are the second most common cause of adult emergency admission to UK hospitals (Health Foundation, 2017). However, evidence shows that many of these admissions are avoidable with the correct management of the condition (Department of Health, 2012a).

Greenhalgh et al (2010) point out that most patients with a long-term condition (LTC) remain in their own homes. Management of chronic LTCs is now a central task for community practitioners, and caring for them requires partnership with patients in the long term, rather than providing single, disconnected ‘episodes’ of care (Lorig et al, 2017). This can be achieved by assessing patients and educating them about medicines and therapies they are not already aware of to improve their symptom management and avoid overburdening the NHS.

COPD cannot be reversed, but with careful management and support from the multidisciplinary team (MDT), patients can enhance and improve their quality of life.


Towards self-management

The publication of Five year forward view in England brought about a focus on change, partnership and investment, and also on promoting better experiences, outcomes and use of resources (NHS England, 2014).

The report championed more engagement with patients from healthcare professionals and provided the framework for health and social services to work in partnership with patients and carers to self-manage LTCs to transform the delivery of services in the NHS (Hibbard and Gilburt, 2014).

Promotion of wellbeing and independence and the prevention of ill health for patients could enhance and improve interpartnership working between patients, carers and service providers. NHS England (2012) has also acknowledged the confidence, knowledge and skills people have in managing their own healthcare.

The Carers Act (2004) encouraged patients and carers to self-manage by providing adequate information adapted to their intellectual level. This empowered patients to take control in managing their care independently or in partnership with the MDT (Department of Health, 2012b; NMC, 2008).

What is COPD?

COPD is a group of lung conditions that cause a narrowing of the airways and make it difficult to empty air out of the lungs.

Two of these conditions are persistent bronchitis and emphysema, which can occur together in COPD. 

Bronchitis narrows and inflames the bronchi. People with bronchitis often produce sputum or phlegm.  

Emphysema damages the alveoli in lungs. The sacs break down and cause the lungs to become baggy and full of holes that trap air.

These processes narrow the airways, making it harder to move air in and out while breathing, and the lungs are less able to take in oxygen. COPD impacts heavily on the NHS in the following ways:

  • Common long-term disabling conditions
  • Frequent hospital admissions
  • Many patients remain undiagnosed and are only identified at the point of hospital admission
  • Large variations in care accounting for avoidable mortality.

NHS England, 2018; British Lung Foundation, 2016

Fast facts on COPD
A personalised journey

The author, Susan Nyandoro, designed a personalised COPD passport for patients and staff throughout the trust to ensure the delivery of continuity of care, medicine reconciliation and disease management. Fellow community matron Sandra Herbert assisted with cascading the passport.

The passport promotes high levels of patient activation, an individual’s knowledge, skill and confidence for managing their health and healthcare (Hibbard et al, 2005).

Higher levels of activation mean patients are more likely to engage in positive health behaviours and problem-solve their own care. Other ways in which the passport can help are listed in Benefits of implementing the COPD passport (below).

The new COPD passport will be piloted in mid Devon and then rolled out across other areas for LTCs via community matrons. COPD management has implications for current practice. The NHS may see a reduction in unplanned admissions and expenditure if the condition is managed appropriately. Patients will enjoy an enhanced quality of life and better health choices. An increase in the prevalence of long-term diseases such as COPD is anticipated (Cummings, 2016).

LTC management is proposed for pre-registration training, according to Plymouth University, and nurse training remains under review to cater for care in the community. This would instil knowledge and confidence in new nurses by using a strategic approach to manage patients within their care, promoting care in the community.

In the future, this COPD passport could be part of the roll-out of the new electronic patient record from Epic, planned to go live in the summer of 2020. It is hoped that this will provide a seamless service and improve communication between professional carers and patients, enhancing the delivery of care.  

Benefits of implementing the COPD passport 

  • Promoting patient activation of the disease
  • Professionals’ medicine management and reconciliation
  • Empowering the patient and carers with knowledge of treatments and condition management
  • Better communication between service providers
  • Allowing the patient to be the bearer of the most up-to-date disease management plan and medicine reconciliation
  • Reduction of hospital admissions
  • Reduction of exacerbations of COPD
  • Symptom control
  • Self-management of medicines
  • Self-implementation of the rescue plan (self-efficacy)
  • Increasing independence.

Susan Nyandoro and Sandra Herbert are community matrons at the Royal Devon and Exeter NHS Foundation Trust. 


Image Credit | Superstock


British Lung Foundation. (2016) COPD (chronic obstructive pulmonary disease). See: (accessed 11 October 2018).

Cummings J. (2016) Leading change, adding value: a framework for nursing, midwifery and care staff. See: (accessed 4 October 2018).

Carers (Equal Opportunity) Act. (2004) See: (accessed 4 October 2018).

Department of Health. (2012a) COPD commissioning toolkit. See: (accessed 23 October 2018).

Department of Health. (2012b) Liberating the NHS: no decision about me, without me. See: (accessed 4 October 2018).

Greenhalgh T, Heath I (2010). Measuring quality in the therapeutic relationship. See: (accessed 4 October 2018).

Health Foundation. (2017) Variation in patient pathways and hospital admissions for exacerbations of COPD: linking the National COPD Audit with CPRD data. See: (accessed 23 October 2018).

Hibbard JH, Mahoney ER, Stockard J, Tusler M, (2005) Development and testing of a short form of the patient activation measure. Health Services Research 40(6): 1918–30.

Hibbard J, Gilburt H. (2014) Supporting people to manage their health: an introduction to patient activation. See: (accessed 4 October 2018).

Lorig K. (2017) Commentary on ‘evidence-based self-management programs for seniors and other with chronic diseases’: patient experience–patient health–return on investment. Journal of Ambulatory Care Management 40(3): 185-8.

NHS England. (2018) Improving outcomes in chronic obstructive pulmonary disease (COPD). (accessed 11 October 2018).

NICE. (2010) Chronic obstructive pulmonary disease in over 16s: diagnosis and management. See: (accessed 4 October 2018).

NMC. (2015) The code. See: (accessed 4 October 2018).

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