Meeting COPD Challenges with The Care Pathway (Part 1)

The Seriousness of COPD 

  COPD is one of the world’s biggest killers, being the 3rd4th and 5th leading causes of death in USA, Canada and UK respectively. It’s a progressive condition where the patient’s life expectancy decreases at each stage of the disease, so a lot of COPD management is catered towards optimizing the health of the patient when they are at home. The idea is to slow down the disease progression. The frequency and severity of symptoms increase with each stage. It leads to a decline of lung function and more hospitalizations. Half of all COPD patients report problems sleeping, and 70% of them say their physical activities become restricted. Thus, patients, clinicians and solution providers are always looking for new ways to better handle COPD. 

Exploring the Role of Care Pathway in COPD Management 

  COPD is an extensively researched condition amongst doctors and academics. It can be difficult to generate any consensus as research can often produce contradictory findings. It’s difficult to pin down the cause of COPD on any one thing. But from looking at COPD management on the ground, listening to those who work with COPD patients and by monitoring support groups, there are certain issues that require a fresh outlook. 

  Virtual care technology such as the care pathway can play a role in resolving such issues, or at least improve the situation. We dive into what these issues are and how virtual care platforms can make a difference. 

  Pulmonologists and Pulmonology Dept. Heads have a big responsibility in treating and running programs for COPD patients respectively. While COPD symptoms may be suspected at the primary care level, it’s the specialists like pulmonologists that are consulted for a diagnosis and providing input on the treatment plan. In this 3-part series about meeting COPD challenges, we go through three different areas of COPD management. We cover the principal issue in each area and discuss how the care pathway can be used in different ways to address them. 

First up is Chronic Disease Management. 

Chronic Disease Management: Need for Patient Adherence 

  The selection of COPD medication and device type is a major issue that surfaces constantly. There are over 30 approved FDA devices in USA for COPD medication. It’s a similar number for Canada and UK. When physicians prescribe COPD medication, they are not just prescribing the molecule, but the device as well that is used to take the medication.  

  There is no golden rule that suggests “if this, then that” for inhaler selection. A lot of the judgement comes from assessing the functional ability of the patient. So whatever medication and mode of delivery is chosen, it is paramount that the patient adheres to the program. If they don’t, then there is no point in changing medication plans in the future as there isn’t a fair assessment of initial results. Hence, patient education is critical.  

Driving Adherence by Focusing on Patient Education 

  It’s possible to come to the right judgment using years of experience and accrued clinical knowledge. But if the patient cannot be made to adhere, then it will be difficult to evaluate improvements. There needs to be an adherence strategy in place, where it is documented how well the patient follows instructions and how consistently they do everything as they are told. Such adherence can be driven through greater patient education. We further explore how virtual care has a say in this matter via pathways of care. 

Continued Teaching Throughout the Course of Care 

  Luckily, staying in touch with patients has never been easier in today’s age. The rise of connected health means that you can coach patients virtually through video conferencing. Patients can be coached on the correct inhalation techniques for different type of medication devices. Meter Dose Inhalers, dry powder inhalers and nebulizers are all different from each other. It’s important that the patient is taught the right way to use such devices, but also that such practice is perfected over time through repetitions. Such consistent learning is possible through care pathways. These pathways can have automated check in sessions that connect nurses and therapists to patients. It ensures that patients become adept at using medication devices throughout their course of care, and other self-management techniques as well such as pursed lip breathing,  

  All relevant COPD educational materials can be stored in a designated resource center of an organization, says Dr. Barnett, CEO of McKenzie Health System, and former Respiratory Therapist. Videos of exercise demonstrations, and inhaled medication manuals can be stored in one place and integrated into a patient’s care pathway at various points. Educational materials can originate from the organization using the platform, or can be borrowed from another organization. 

Enforcing Behaviors and Proactive Engagement 

  In person lessons and several virtual lessons are great for transmitting expertise to the patient over a period of time. Everybody wins if the patient knows what they are doing and are comfortable on the path that is laid out for them. But knowing how to do something, and doing it, are two different things. To ensure that the healthcare professional and the patient are in sync, reminders can be sent to patients to take the right medication at the right time. If a status update isn’t received from the patient, a smart notification could be sent out to them that nudges them to cooperate.  

  To ensure their engagement in the process, the teach-back method can be enforced virtually, where patients have to explain what they learned. Similarly, they can also report back on their actions to their care providers, in what is proactive engagement. All such touchpoints with the patient can be automated from the get go using the care pathway.  

Providing a Guiding Hand to Care Providers 

  Patients are not the only party that can benefit from coaching. Physicians and nurses have many distractions throughout the day.  Starting from preventing misdiagnosis to determining goals for the patient, a referrable guideline is extremely useful for not overlooking anything, according to Dr. Blagev, Pulmonologist and Medical Director of Quality at Intermountain Healthcare. By implementing a virtual COPD guideline that takes into the account the history and current status of the patient, healthcare professionals can be guided on the best action to take at each step of the workflow in the care pathway. 

Interested in the second part of this blog series? Click here to learn more about the all-important issue of care transitions for COPD patients.

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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