Meeting COPD Challenges with The Care Pathway (Part 3)

  This is the final part of our tripart series on meeting COPD challenges with Virtual Care. To recap, the 1st part covered using education to drive patient adherence in managing COPD. The 2nd part focused on the period right after a patient is discharged, where virtually monitoring the patient is crucial. Part 3 deals with the long-term connectivity and care of the patient.  As COPD is an irreversible chronic disease, the patient is never quite let off the hook. There is a reason why most COPD guidelines have stages to them. If we take the GOLD Guideline for example, a patient advancing to a severe or end of life stage is dangerous. That’s why even when everything seems to be going well, it is good to remain connected with patients. 

Reaching Isolated Patients: Need for Connection and Health Maintenance 

Patient isolation starves COPD patients of human connections, which is needed for achieving greater patient engagement, which in turn leads to better health outcomes. There is another hidden ill associated with patient isolation. It leads to indifference over time and accepting limitations. Such signs are misinterpreted to be positive just because symptoms are controlled. But it ignores the drop in quality of life for the patients as they are rendered increasingly immobile.  

Supporting Patients on the Long Run by Maintaining a Communication Channel 

Healthcare professionals thus have to proactively ask patients how they are doing, and if they are satisfied with their COPD management. Surveys can be sent out that ask them to indicate their level of comfort or agreement. When this is done, patients are able to express themselves and a lot of information comes out that paints a more accurate picture of their current condition. We look at some ways in which care providers and patients can remain in touch via virtual care. 

Empowering Respiratory Therapists 

  There are limited Respiratory Therapists outside the hospital setting. Despite them playing an essential role in the care for COPD patients, three fourths of them are employed by acute care hospitals. To cover for their shortage, one respiratory therapist can be connected to multiple patients at once via a virtual care platform. So despite being stationed in a hospital, the RTs can be involved in greater community outreach by managing multiple patients enrolled in various COPD programs. For RTs working in clinics, they can do the same in community based chronic care programs administered by primary care clinics. By onboarding multiple patients to their group, they can manage multiple cases at once and be more efficient. 

Distant Therapeutic Interventions 

  COPD is a chronic disease that weakens patients over time. In order to reduce their suffering, sometimes out of the box thinking is required. Incorporating mindfulness into their daily practice is one such idea. Physicians testify on the emotional and attitudinal components of COPD care.  Dr. Benzo, Director of the Mayo Clinic Mindful Breathing Laboratory, says that COPD treatment can be subjective to how the patient receives it. This is where mindfulness makes a big difference as patients become more accepting of their condition and are more likely to have a positive outlook and change their behavior. If this leads to smoking cessation, then it’s a big win for them, as continued smoking throughout COPD is a leading cause of COPD progression. Mindfulness group sessions can be delivered as a distance intervention which is a great use of virtual care platforms. Such sessions can be part of care pathways to build a rapport with patients over time. 

Considering All Possible Scenarios when Maintaining Dialogue with a Patient 

  Although there are guidelines in place to treat COPD, Dr. Keller of University of Washington says that patients can deviate from the course. So it’s fine to use one’s discretion to suggest treatment that works best for individual patients. It’s okay to consider different therapies if the patient is not able to use a certain device. Vaccinations and smoking cessation therapies should be considered if it prevents further harm to the patient. The workflows created in the care pathways can be very elaborate. They can include such options if it comes down to other paths not working. In later, more severe stages of COPD, oxygen tank therapy may need to be incorporated as a part of the pathway. 

  Considering people’s co-morbidities is essential for COPD treatment, as it is a better predictor of mortality than just considering frequency of COPD exacerbations. It’s possible to stratify COPD patients by risk in a virtual care platform. A nurse can have a glimpse of all patients in the system and identify which patients are in higher risk of danger.  

If you are interested in learning more about how the Aetonix aTouchAway platform can help with patient management, click here.

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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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