Should your organization implement a chronic disease management program?

It seems that more organizations than ever are implementing chronic disease manage programs – and for good reason. The World Health Organization predicts that chronic disease prevalence is expected to rise by 57% by the year 2020. A chronic disease is defined as a condition lasting three months or more and generally unpreventable and incurable. These could include conditions like asthma, diabetes, and chronic obstructive pulmonary disease (COPD), among many others. Although they are typically incurable, there are measures that can be taken to ensure they do not worsen. If a chronic disease is left untreated, it could be the cause of other related diseases and health problems. Fortunately, many organizations have introduced programs to empower complex patients to be in control of their conditions. If your organization has not yet taken this step, this blog post will give you 3 reasons to consider it.

Enabling self-management

According to the Centers for Disease Control and Prevention, 90% of Canada’s $3.3 trillion in annual healthcare spending is for people with chronic or mental health conditions. These costs could include frequent visits to the patient’s physician/care team, hospital readmissions, specialized tests, and more. Fortunately, there is a much easier, less expensive way of providing chronic care. Some mobile applications are designed to enable care providers to virtually coach their complex patients using a phone or tablet. The only challenging task is finding the right app that will work for both you and your patient. Using an app can allow the care providers to set reminders and alerts instructing the patient on medications and appointments. If a patient is set up with the proper equipment, they will also be able to measure their blood pressure, body temperature, weight, and share the data with you through the app. Giving patients the ability to track their health from the comfort of their time can make them feel much more empowered in their care. They are able to be more in control of their condition and keep you in the loop without requiring in-person visits. This can drastically free up your staff’s time as it eliminates travel time. A simple video call with a complex patient could avoid them having to come in to your office. Some organizations have introduced softwares of this kind to their chronic care programs. One of these organizations is the Lennox and Addington County General Hospital in Napanee, Ontario.

Introducing a support system

The Lennox and Addington County General Hospital have introduced a chronic disease management program for patients specifically with COPD, called BREATHE. The program sets the patients up with a tablet using the software aTouchAway by Aetonix. aTouchAway is an innovative mobile platform for remote complex care management. The BREATHE program also sets the patient up with an internal medicine specialist, respiratory rehabilitation, emotional and spiritual support from their hospice program, a registered dietician, the BREATHE clinic, and pulmonary function testing. It includes home support within 48 hours with the rapid response nurse and follow up with the primary care provider within one week of discharge. Chronic diseases are hard enough to manage with a care team, but even harder when a patient lacks that social support. This program and other chronic disease programs are especially useful to those patients. 25% of Americans report they have no one to discuss with about matters that are important to them. Joining a specialized program and having access to all the healthcare assistance they need can drastically reduce the social isolation a patient may feel. Having access to these various specialists and healthcare providers can enable the patient to ask for simple advice or video conference them if they are experiencing issues. This direct communication can help to avoid hospital admissions when it occurs before the problem has a chance to get worse.

An informed patient is an empowered patient

Overall, the main purpose of chronic disease programs is education – teaching patients more about their condition(s), how to manage them, and available resources. Some organizations opt for a different approach than above. Some may offer classes on specific diseases. These can include education around diet and exercise, early symptom recognition, and general management. They may also learn how to manage other factors like stress and lifestyle changes that may come with a recent diagnosis. Offering hour long classes will prove to be much more cost effective than sending a patient off with a handout. When a patient and their loved ones are informed of how to properly care for their condition, the care they receive will be much better. As a result of these benefits and others, organizations will find themselves operating more cost-effectively. Providing patients with the ability to proactively manage their chronic conditions themselves allows for staff to provide more care to more patients. Informed and enabled patients are much less likely to be subject to costly hospital readmissions as well. The Lennox and Addington General County Hospital, as mentioned earlier, noticed they were able to reduce readmission rates from 17% to 3% through their COPD management program within a year. If your organization is considering implementing a chronic disease management program, there has never been a better time. Featured image courtesy of USA Today 

Featured image courtesy of Wikipedia.

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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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