Abstract

Background and Aim:
Southampton has a high prevalence of COPD, with rates exceeding 8% in deprived Primary Care Networks (PCNs), alongside high smoking rates (up to 28%) and pollution-related mortality. Patients with COPD who are vulnerable to exacerbations are considered to have ‘rising risk’; they are often unknown to services and from deprived communities, leading to poor outcomes and inequitable care. This project aimed to proactively identify and support rising risk COPD patients through specialist nurse-led reviews to deliver value-based care, enhance self-management, and address health inequalities in preparation for winter.

Methods:
Using an Ardens search tool, two high deprivation PCNs (Living Well Partnership and Southampton Central) identified 495 patients based on COPD diagnosis and at least one course of antibiotics or oral corticosteroids in the last 12 months. After manual case note review, 66 patients received a comprehensive review in the community within a 2-month period. Reviews delivered treatment optimisation, pulmonary rehabilitation referral, tobacco dependency support, inhaler technique review, vaccination delivery, psychosocial support, and education with self-management. Self-management support included access to the digital self-management tool, myCOPD. In addition, a single-point of access telephone line was provided for patients to use if more support was needed at the time of exacerbation.

Results:
Medication was optimised in 17% of patients, 33% had inhaler technique improved, and 18% received new rescue packs. Pulmonary rehabilitation referrals were made for 12%, with 19% of smokers referred to tobacco dependency services. Psychosocial support was offered to 65%, with 19% referred to psychological or social services. Of those referred to myCOPD, 76% activated the app. Patient feedback showed 72% felt supported, 62% reported improved COPD management, and 76% would recommend the review. Staff highlighted the need for specialist skills, an integrated approach with support from wider community teams, and improved search tools.

Conclusions:
A targeted approach to deliver specialist nurse-led reviews can effectively identify and address clinical and psychosocial needs of rising risk COPD patients in deprived populations. Robust search tools, multidisciplinary collaboration, and digital support are critical for successful implementation. National evaluation and meta-analysis will inform future scale up, balancing quality with broader reach.