Network care (COPDnet)
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Network care (COPDnet)

Network care (COPDnet)

COPDnet is an initiative of the lung diseases department of Radboudumc. The initiative's ambition is to improve the outcomes and efficiency of care for people with chronic respiratory disease (asthma and COPD). This is achieved by creating, implementing and testing a new transmural chain care model. The model is designed on the basis of recent insights into effective strategies for chronic conditions such as the Chronic Care model and insights into integral banding of people with chronic respiratory disease. The COPDnet model emphasizes the non-drug intervention options. In addition, a quality system is applied that is based on systematic feedback on the outcomes of care to healthcare professionals. The model starts with a diagnostic trajectory in the second line aimed at analysis of the integrated health status and activation for self-management. On the basis of this analysis and in close consultation with the patient, an individual care plan is drawn up. Implementation of the care plan depends on what is needed and the patient's preference. This can be done by means of intervention modules in primary care, or in more complex situations, through multidisciplinary pulmonary rehabilitation. In any case, the starting point is tailor-made care. The regions that work with the COPDnet model (currently Nijmegen and Uden) are nationally connected.

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