TABLE 1

Advanced Lung Disease Service key components

1)Respiratory and palliative care offered together, to provide individualised care which addresses the underlying respiratory disease, symptoms and psychosocial issues
2)Disease treatment optimisation including: optimising inhaler therapy and device technique, smoking cessation support, pulmonary rehabilitation referral, and domiciliary oxygen therapy assessment, education and management
3)Comprehensive management of refractory breathlessness, with nonpharmacological strategies (such as breathing techniques, recovery breathing positions, the use of a handheld fan) and opioids as required; individualised written breathlessness plans and written breathlessness resources provided
4)Self-management support including patient and family education regarding disease and symptom management, with provision of written exacerbation action plans
5)Routine discussions regarding goals of care and advance care planning
6)Patient- and family-focused care including extended 1-h consultations, urgent reviews and rapid access (<1 week) for new referrals as needed
7)Specific carer support including facilitating access to respite care and bereavement support
8)Long-term follow-up with continuity of care in clinic and nonabandonment
9)Telephone support and home visits provided by a respiratory nurse consultant
10)Early access to “Hospital in the Home” care to avoid respiratory admissions
11)Respiratory care and service coordination, and integration with other community services, including aged care assessment services
12)Focus on early communication with, and support of, general practitioners and other health professionals, including teleconferences