Helping COPD patients BREATHE easily

Chronic Obstructive Pulmonary Disease (COPD) is described as a group of respiratory diseases that can result in shortness of breath, chronic coughing, wheezing, weight loss, and more. More than 90% of people with COPD are smokers or used to smoke, and the disease is becoming more and more frequently diagnosed in Canada over the last few years. In fact, COPD is currently the fourth most frequent cause of hospital admissions for Canadian men and sixth for the women. The costs of this disease really add up for our healthcare system. It is estimated that each patient costs around $2000 annually – this amounts to around $1.5 billion dollars a year.

Getting inspired

In an attempt to lower these costs and improve patient care, hospitals across the country are coming up with their own innovative approaches. The Queen Elizabeth II Health Sciences Centre in Halifax was the first to pilot the INSPIRED (Implementing a Novel and Supportive Program of Individualized care for patients and families living with Respiratory Disease) program for patients who are living with COPD. INSPIRED works to keep patients out of the hospital through frequent outreach and providing them with the resources to self-manage their own care from home. INSPIRED provides patients with four in-home visits following their arrival back home from the hospital along with monthly check-ups over the phone. Patients also have access to other forms of support including a toll-free helpline and educational resources.

Patients like David Smith of Halifax are finding this program life-changing. He enrolled in the program after he was admitted to the emergency room five times over just two years. With every visit, he was certain that he was not going to make it. Since he’s been involved with INSPIRED, he is now back to fishing and gardening like he used to. Not only does this program give patients a greater sense of confidence and support, it is also saving a significant amount of money for the system. Results have shownthat for every dollar invested in this program, results in saving $21. Because of the effectiveness of INSPIRED, the Canadian Foundation for Healthcare Improvement (with additional funding from Boehringer Ingelheim Canada) has funded 19 more of these programs across Canada. Of course, with such a strong and practical model being deployed throughout the country, other organizations have taken notice.

Innovative BREATHE program

One of these organizations is the Lennox & Addington County General Hospital. The LACGH is located in Napanee, Ontario and has created BREATHE – their own program adapted from and based on the original INSPIRED model. The BREATHE program has been piloted with a small group of patients with the goal of further refinement and rollout across the South East Local Health Integration Network. In the first six months of the pilot, the hospital had 0 respiratory related readmissions. Registered Respiratory Therapists check in with patients weekly through Aetonix’s mobile app, aTouchAway.

The biggest difference between BREATHE and INSPIRED is that BREATHE does not include in-home visits. Instead, regular interactions are done through aTouchAway, a communication and information sharing platform used to connect the circle of care. The care team uses the reminders feature for daily check-ins. Reminders allow them to ask patients simple questions to gauge their condition and follow up through a phone or video call if necessary. Patients and family members that are part of this program also have access to a registered dietitian, the BREATHE respiratory clinic, COPD education, a mobile tablet with the aTouchAway software, and more. Waking up in the middle of the night and hardly being able to breathe is enough to cause anxiety for anyone. Fortunately, having 24/7 access to self-help material and a telephone helpline is decreasing the number of ER visits. The diagram above shows the BREATHE program timeline.

With innovative approaches like the BREATHE and INSPIRED programs, there is reason to be hopeful that more COPD patients will soon be able to self-manage their care from their home instead of being treated in the hospital. Hospitalizations as a result of COPD can often last up to ten days. With these out-patient programs, patients are able to treat their symptoms before  escalating to an acute COPD exacerbation requiring an ED visit or hospital admission. If more facilities continue to adopt the models of these two programs, it will change how COPD patients manage their care. Patients receive improved supports from the comfort of  home and have a much lower risk of being (re)admitted. The system benefits as these new models of care are proven to save time, money and resources. If you are affected by or providing care for someone with COPD and are interested in learning more about BREATHE contact us and we’ll put you in touch.

Featured image courtesy of 93.1 FM.

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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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