Standardized care plan for patients with COPD in Long-term non-invasive ventilation in a home setting

<bold>Background:</bold> Long-term non-invasive ventilation (LT-NIV) is challenged by non-persistence in treatment. Follow up is essential to keep patients adherent. By standardized care plans (SCP) specified patient groups can be offered consistent care. <bold>Aim:</bold> To evaluate the use of a SCP and the need for unscheduled contacts. <bold>Methods:</bold> A real-life study evaluating a one-year SCP in patients with COPD, treated with LT-NIV, both ongoing (O), and newly started (NS). Follow up was carried out in collaboration between specialized outpatient clinic and homecare provider AirLiquide (AL). The SCP contained 2-3 outpatient clinic visits, 3 homecare visits (mask fitting, nocturnal SO₂- and CO₂ measurements, and adherence), and 1-3 phone calls by AL (adherence). Patients were instructed to contact the AL call-center with questions and for troubleshooting. Unscheduled visits and -calls were registered by AL. <bold>Results:</bold> Fifty patients (25O/25NS) were included. To date 21 patients completed study, 9 nine died, 20 patients are active, no patients discontinued treatment. SCP was followed by all patients, except 12 hospital visits that were changed to home visits. One extra visit in LT-NIV clinic was carried out. In total 243 (117O/126NS) unscheduled visits were registered. Visits purposes were to mask-fitting, technical issues, delivery of supplies, training of homecare nurses and extra capnography/ SO₂ monitoring. Number of extra calls from/to patients were 104(41O/63NS)/136(59O/77NS) respectively. <bold>Conclusion:</bold> SCP can serve as a framework, but a personalized care plan is important to ensure persistent use of LT-NIV.