Coming up with a Patient’s COPD Journey. 8 Stages Identified.


Perhaps no other condition in the medical books have burdened hospitals more than Chronic Obstructive Pulmonary Disease (COPD). As it’s a chronic condition, hospitalization and care treatment costs can add up very quickly if the situation is not brought under control and maintained at a manageable level. It’s also a major hassle for the patient, to first seek optimal care while getting accustomed to the condition, and then to possibly deal with it for the rest of their lives, such is the nature of such chronic conditions. The one thing that screams out loud from this whole ordeal is that a long-term care relationship must be developed between the provider and the patient. Hospital economics back up the need for such a bonding as illustrated below vis a vis three perspectives.

If we adopt a revenue centric approach, COPD cases will exhaust hospital resources, thus blocking capacity to treat more profitable acute care cases. From a marketing point of view, the hospital won’t even get to reach new portfolios of patients, thereby foregoing its chance to build or market its expertise in other areas. If we adopt a cost centric approach, COPD treatment is pricey. Hospitalizations and inpatient treatments are always expensive, and having a steady diet of just COPD cases, a condition notorious for lengthy average stays, and high readmission rates, is not ideal. The outcome-centric approach is directly tied to the cost-centric approach, whereby improving the outcome of the patients, one can also reduce costs. But COPD is such a condition where improving the outcome consists of lifestyle changes, and continuous monitoring to prevent flare ups, and also necessary virtual action plans once there are flare ups. Thus, its seen more as a commitment to a patient, and not merely the performance of service.

The above scenarios prove that whatever angle you approach COPD from, the goal should be to quickly and effectively treat the patient, but then to also maintain a relationship with them. If this is not done properly, the hospital will take a hit on all three fronts of revenue, costs, and of course outcome, as chronic diseases like COPD can be quite pestilent. To reduce symptoms may take a lifelong commitment of engagement, where the provider and patient are both proactive in keeping the symptoms stable, and hopefully restore them back to pre-diagnosis levels (though this is very rare).

The COPD Patient Journey

It’s important then to devise a patient journey map when it comes to COPD treatment. A patient journey map depicts the average patient’s experience of a condition, from the onset of symptoms, to diagnosis, and finally treatment that ends in some form of resolution. The objective is now for hospitals to figure out where they can add value in this continuum of care, from early awareness, to admission, to discharge, to discharge post monitoring.

We’ve looked at two patient journey maps, courtesy of idea illustration agency Fuselight, and an academic paper detailing the point of view of the COPD patient, to come up with our own comprehensive patient care journey. This type of insight using the patient as the focal point, is very important to understanding the future of COPD. Care models have already begun to shift, with more focus on accountability. Thus ,the question should be the following: Do I have enough understanding of every patient from the first point of contact, to understand if I can 1) Correctly diagnose COPD 2) Prevent exacerbation 3) Ensure effective implementation of care plan?

Both qualitative and quantitative studies should be conducted to describe the typical COPD patient’s journey through the healthcare system and all of the obstacles they face. But here is our understanding from the aforementioned resources. Operation specialists and care management executives should scrutinize this workflow, so it can be streamlined. Though, just a word of caution, there is such thing called specialized cases which deviate from the normal, and which require an unique mix of treatment. But apart from such cases, any business always looks to optimize the care process. Doing so curbs costs and increases efficiency, ensuring that the business can continue existing and serving the cause in question, which in this case is the effective treatment of COPD. At the rate at which hospitals are closing or are being consolidated, process matters. So without wasting any more words, here is our patient journey for COPD. It’s presented in a textual format. In the future, a pictoral version of this article will be uploaded.

Stage 1: Symptoms Faced

It all begins with chronic cough. At this stage, the future patient is not yet thinking about going to the doctor. The top three symptoms are: Cough (with or without mucus), mucus clearance of lungs and shortness of breath. As these symptoms exacerbate, the patient is forced into making a doctor’s appointment. Education and awareness building about early symptom detection would be a great addition to the process at this stage. Rather than wait for the first major lung attack, it is better to enroll earlier to A COPD program to prevent exacerbation while there is still a chance.

Stage 2: 1st HCP Visit

In the patient’s first visit to a healthcare provider, the mentioned symptoms will alert most primary physicians to the possibility of a COPD, asthma, or other respiratory related diseases. A FEV (Forced Expiratory Volume) and/or a chest X-ray may be conducted. Depending on these results, a COPD diagnosis might me immediate. If not, the patient enters into step 3.

Stage 3: Awaiting Confirmation

Some potential wait time may be faced at this stage. The patient will share news about undergoing the diagnostic tests with friends and family, and seek more information online and in other channels about the procedures faced and likelihood of a positive diagnosis. There is an opportunity at this stage to direct more information to the patient, about the future steps. There is a lot of uncertainty in the minds of the patients, and it could be a good time to calm their nerves and explain the road that lies ahead for them.

Stage 4: Confirmation of Diagnosis

A specialist, usually a pulmonologist, might be consulted at this stage to confirm the diagnosis. There is also the chance of misdiagnosis, in which case the patient will wrongly continue on this path before the correct diagnosis can be confirmed. Once the diagnosis is confirmed, the patient will talk to physicians either in office or online via telehealth about the significance of the test results. If not satisfied with the counsel, they will go online to seek answers. Again, as with stage 3, there is an opportunity here for more education. It may be a good idea to talk with the patients about the dangers of misdiagnosis as well. As long as the communication channels are being kept open, any doubts and fears can be expelled.

Stage 5: Post diagnosis Confirmation. Start of Care Plan & Discharge

Two weeks after confirmation, the patient comes back to have the Pulmonary Function Test (PFT) done.  Respirologist, used interchangeably with pulmonologist in some organizations, gets results from test and conveys accordingly to patient’s doctor. The doctor prescribes medication. The patient is subjected to many lifestyle change programs such as smoking cessation, if he or she is a smoker, or a diet plan for those who are overweight. Inhalers may also be prescribed at this stage.

Before discharge, many things are explained to the patient such as Inhaler Technique education, Dietitian and Physical Therapy assessment, etc. At this point of care, the patient journey may or may not involve a remote patient monitoring component. If the patient is to be monitored remotely, then the ins and outs of the RPM program is explained, including access to a helpline, or referral to inpatient or outpatient pulmonary rehabilitation program.

There is a large vacuum in this stage about the accountability of education. Inhalers aren’t always explained, and many patients refer to pharmacists after the general practitioners give them medicines. Also, from the whole journey’s perspective, stage 5 may be the most crucial as it packs so many things into one episode just before discharge and commencement of the care plan. It is also the stage, where the patient may first be introduced to the idea of a remote monitoring program (RPM). If it will help keep in touch with the patients down the road, and ensure adherence of medication and lifestyle programs and administer emergency virtual visits, then a proper onboarding process is necessary for the patient. Also, the choice of rehabilitation programs is a major decision that is to be made, regarding the intensity levels of the program, and the location.

Stage 6: First Assessment

In the early assessment stage, further tests are done to see if there is progress, or if there are any complications, or worse still regression. The COPD 6 test, or more PFTs may be conducted. The COPD patient gets to know the respirologists, respiratory therapists and nurse practitioners pretty well here as they regularly counsel the patient and fill in the gaps where there might be questions. At the end of this stage, the patient is referred back to the GP who writes them a COPD action plan. There is a load management issue on the side of providers at this stage, as they look to first serve the high-risk groups out of the whole COPD population that meet necessary criteria. It is important to mandate what all the different care providers’ roles are at this stage, and how they can contribute to the betterment of the patient.

Stage 7: 2nd Assessment

At this point of the patient’s journey, either respiratory conditions are stabilized or there are signs of steady improvement. However, there is a chance of regression as well, upon which the patient will be referred to a specialist and new medications may be prescribed. If conditions don’t improve, or continue to worsen, it is a worrisome time for the patient. They seek second opinions on the medications being prescribed. Exercise can also be stopped at this stage, if the physical conditions do not permit it. There are many mentions of difficulty here, the two major categories being physical and emotional. Top 3 physical difficulties are mucus clearance, impedance on daily Activities, and poor sleep quality. The top 3 emotional difficulties are sadness, anxiety and depression. Balking the downward spiral of the patient at this stage can be considered a success, depending on the gravity of the situation.

Stage 8: O2 Therapy

Eventually if the symptoms keep aggravating, then the patient is referred to home oxygen therapy, where they are fitted with O2 cylinders. Sometimes such a state can be brought about by not adhering to the medication or lifestyle changes program. Hence why, RPM programs can and do play such a big role in modern COPD programs. Such a stage is best avoided if possible, as patients report their increased levels of struggle. They have to end up going to ER or use urgent care more frequently because of incidents like breathlessness or respiratory infections. From here onwards, if the patient’s condition plummets further, they may be transferred to hospice, especially if they have emerging complications or bad cases of comorbidities. The freefall of quality of life is quite one sided in both stages 7 and 8, and more research on medicine must be conducted to see if such patients’ fortunes can be overturned.


COPD can be tough pill to digest. It is the only chronic disease in USA, where the mortality rate is still rising.  It requires cooperation and fortitudinous will on the part of the patient, and a stellar COPD program that absorbs all cases and churns out the best possible outcome on the part of hospitals. By understanding each step of the process, it is my firm belief, that hospitals can advance towards true person-centered care. In chronic diseases such as COPD, it may be their best shot for a provider organization to separate itself from the rest of the pack. It’s not like there is a lack of incentives, with everything shifting towards more value-based care, and both state and federal laws loosening up to monetize provision of remote care programs.

What do you think of the 8 steps of the COPD journey?  Email me at Or let us know on our media channels.

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We are Aetonix. We simplify complex healthcare. Full disclosure, we are in Telehealth. But we are involved in Remote Patient Monitoring for those who needed it most, patients suffering from complex needs.


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COPD Education – Onboarding


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

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

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
COPD Education – Continuous Maintenance


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

Patient, Educator (Nurse, RT or Physician)

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 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).
COPD Respiratory Status Follow-up


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

Patient, Educator (Nurse, RT or Physician)

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.
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