Neighbourhood care COPD prevention program


The goal of the project is to establish a partnership in the chain to help prevent exacerbations or flare-ups in COPD patients in neighbourhoods.

Project description

COPD patients often have exacerbations that cause lung complications to suddenly become worse and hospitalisation is necessary in many cases. The long-term health repercussions of an attack for a COPD patient become greater in the long term and the quality of life continues to decline. As a result, more care is required after each admission and the pressure on district nurses, GPs and hospitals increases further.

In this project, we want to set up a partnership in the chain to help prevent exacerbations in COPD patients in the district.

SmartCOPD is used to support this collaborative process. SmartCOPD is a digital lung disease action plan, including a digital monitoring system and exercise programme (Fitbit smartwatch and coaching) from provider Viduet. In cooperation with LUMC, the effectiveness of SmartCOPD has been demonstrated in research. The use of SmartCOPD has reduced hospital admissions by 69% and length of stay by 79% [Buul et al, 2021]. The client is set up on the activity tracker on the basis of a personal exercise programme. If the exercise programme is not or insufficiently carried out, the client receives a signal. If necessary, a signal is sent to the informal carers. The district nursing officer monitors the progress together with the client and adjusts the exercise objectives if necessary.

SmartCOPD supports the collaboration in the chain based on the client’s own direction, giving the chain partners access to the right information at the right time as part of the prevention programme in the COPD chain.

By implementing this joint intervention programme in the chain between the neighbourhood care district teams, the lung specialist, general practitioners and physiotherapists in the Almkerk region, we want to support the first-line care of COPD patients from district nursing. The aim is to organise care more efficiently and to reduce hospital admissions, to reduce the pressure on GP care and to improve the quality of life of COPD patients.




Grant scheme district nursing support round 1

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