Meeting COPD Challenges with The Care Pathway (Part 2)

This is the 2nd part of our Meeting COPD Challenges with Virtual Care 3-part series. The 1st installment dealt with chronic disease management. It centered around education and ensuring adherence to a care plan in the treatment of a COPD Patient. Part 2 tackles the all-important issue of care transitions for COPD patients. 

Care Transitions: Need for monitoring the patient during the transitory and post-transitory period. 

  Sadly, exacerbations, otherwise known as flare ups, are a very common element in COPD. Almost 30% of COPD hospitalizations are first time hospitalizations because of exacerbations. So there is a trend of a large number of COPD patients admitting to hospital ERs (A&Es in UK) suffering from a shortness of breath. When such patients’ conditions are restored, they are discharged from the hospital. 

Setting up Monitoring by Providing Each Patient a Virtual Portal 

  The nurses in charge of COPD care in hospitals admit that recently discharged patients are most vulnerable. They have more cough, more fatigue, and need to use quick acting inhalers more often. But ironically, it’s during this time of transition that patients are left to fend for themselves. Complications may occur before any scheduled follow up visits if they are transferred to their homes. If transferred to long term care facilities, there may be an information lag where it takes a few days for the new facility to get the full updates of the discharge summary. Such scenarios can be avoided if the patient has a virtual care portal accessible by anyone that is given access. We further investigate below. 

Continuous Visibility of the Patient 

  All nurses who care for COPD patients are unanimous in expressing the need for a standardized approach. Such an approach always includes an action plan that instructs the patients on the best course of action to take during exacerbations. Care pathways can be fitted with action plans, so patients and their caregivers know what to do in such situations. Other relevant forms containing important information such as medication reconciliation can also be included in the care pathway. Whether the patient is at home, or at a nursing home, the receiving party to such plans and forms will have instantaneous access to them as soon as they are made available. There need not be any sudden lull in communication just as the patient is discharged.  

Analytics on Trending Data 

   Having an action plan is necessary, but it is not good enough. More effort should be focused towards the pre-exacerbation period. By exercising anticipatory vigilance, it is possible to differentiate between a normal day vs a non-normal day. By being more cautious in non-normal days, one can anticipate exacerbations before they happen. Clearly, more data points need to be collected. The data most are familiar with is the blood oxygen saturation levels that can be measured remotely via a Bluetooth pulse oximeter connected to a virtual care platform. Additionally, if there was a way to measure the number of coughs or the number of gasps of air, it would make for a richer dataset. More accurate warning signs could be derived from such a dataset. 

Facilitating Pulmonary Rehab 

  Despite the success of pulmonary rehab programs, only 2.7% of COPD patients get referred to such programs after the first year of their discharge. Those patients referred to pulmonary rehab post discharge are more compliant and experience fewer adverse symptoms. Jasmine Holloway, Director, Center for Evidence-Based Care at UnityPoint Health System says that there is a lack of standardized care across their healthcare settings, and lack of rehabilitation referrals is a part of it. Part of the challenge of pulmonary rehab is buying everyone’s commitment to coordination. It’s a multidisciplinary effort that involves primary care doctors, pulmonologists, pharmacists, nurse practitioners, respiratory therapists, caregivers and last but not least the patients themselves.  

  The great thing about a care pathway is that everyone’s role in the patient’s journey is clearly defined. If someone’s input or action is needed at any step of the workflow, that person can be easily contacted and even alerted through the system. Pulmonary rehab has been shown to modify behavior of patients. Different actors are able to motivate the patient, encouraging a better diet, developing an exercise regimen and helping the patient to stop smoking, if they smoke. The care pathway makes everyone collaborate on the patient’s improvement post transition and ensures that the patient doesn’t just fall off the deep end. 

Interested in the third part of this blog series? Click here to read about the long-term connectivity and care of the patient.

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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.

  • 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
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).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB breathing 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).
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.

  • 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.