Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes

Abstract

Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient’s health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.

Assessing the Associations of Patient-Reported Perceptions of Patient-Centered Care as Supplemental Measures of Health Care Quality in VA

“…Interestingly, individuals who had both ≥ 1 prior-year IP and ER visits reported lower perceptions of chronic illness care follow-up/care coordination. Literature stresses the importance of follow-up and care coordination for individuals with chronic conditions following an IP or ER visit, 34 and these aspects of care may require additional emphasis for individuals with a experiences. This indicates that the PREM scores used in this study may have identified several specific areas where targeted improvement efforts could be focused (e.g., increasing efforts at follow-up/care coordination; fostering empathic provider communication; improving patients' general health care experiences), and further underscores the value in using PREMs to evaluate facility performance and improve care delivery.…”

Illness experiences of persons with chronic obstructive pulmonary disease: self-perceived efficacy of home-based pulmonary rehabilitation

“…This qualitative research in health reveals a self-perceived GOLD standard of pulmonary functioning constructed by chronic-ill Spanish persons 11 . Ironically, the subjective idiom of distress 12 differs from -even contests -the internationally-recognized biomedical GOLD standard 1 .…”

“…Despite increasing qualitative studies of COPD 8,9,10,11 , its human calculus is poorly understood. What is lacking is a dense ethnographic description of COPD as a "cultural idiom of distress" 12 .…”

'INSPIRED' Approaches to Better Care for Patients with Advanced COPD

“…Much has been written about the merits of alternative models of care to address the needs of patients and caregivers who are living with advanced COPD [22][23][24][25]. Patients and family caregivers have repeatedly given voice to these concepts [7,9,26].…”

“…Chronic care for COPD must reach beyond the primary care practice into patients' lives in the community on one hand, and yet link into emergency room and inpatient practices on the other hand [23]. planning issues.…”