The COPDnet integrated care model

Koolen, Noortje; Wees, Philip J. van der; Westert, Gert P; Dekhuijzen, Richard; Heijdra, Yvonne F.; Hul, Alex J van ’t

doi:10.2147/copd.s150820

Cited by 23 publications

(29 citation statements)

References 63 publications

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“…The issues relating to the delivery of ACP reported here (appropriateness of care: uncertainty over who is best placed to deliver this, GP or respiratory nurse; ability to engage, mixed views from patients) correspond with those in a systematic review of preferences and practices in ACP for chronic respiratory diseases 29. Wagner’s chronic care model36 37 underpins many current models of COPD care38 39 with its emphasis on the need for proactive, planned and integrated care across the health system. While there is international13 and NZ40 evidence from randomised clinical trials that integrated disease management for COPD improves patients’ quality of life and reduces hospital admissions, the integration of these models into routine clinical practice remains problematic 41 42.…”

Section: Discussionmentioning

confidence: 81%

Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients

et al. 2019

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ObjectivesChronic obstructive pulmonary disease (COPD) is a common chronic disease with significant morbidity and mortality, particularly for Māori, which places a large burden on the New Zealand (NZ) health system. We undertook a qualitative study as part of a mixed-methods implementation research project which aimed to determine the barriers and enablers to the provision of accessible high-quality COPD care.SettingSouthern Health Region of NZ (Otago and Southland).ParticipantsThirteen health professional stakeholders and 23 patients with severe COPD (including one Māori and one Pasifika participant).MethodsSemistructured interviews were undertaken. A thematic analysis using the Levesque conceptual framework for access to healthcare was conducted.ResultsHealth professional stakeholders identified barriers to providing access to health services, in particular: availability (inadequate staffing and resourcing of specialist services and limited geographical availability of pulmonary rehabilitation), affordability (both of regular medication, medication needed for an exacerbation of COPD and the copayment charge for seeing a general practitioner) and appropriateness (a shared model of care across primary and secondary care was needed to facilitate better delivery of key interventions such as pulmonary rehabilitation and advance care planning (ACP). Māori stakeholders highlighted the importance of communication and relationships and the role of whānau (extended family) for support. Patients’ accounts showed variable ability to access services through having a limited understanding of what COPD is, a limited knowledge of services they could access, being unable to attend pulmonary rehabilitation (due to comorbidities) and direct (medication and copayment charges) and indirect (transport) costs.ConclusionsPeople with severe COPD experience multilevel barriers to accessing healthcare in the NZ health system along the pathway of care from diagnosis to ACP. These need to be addressed by local health services if this group of patients are to receive high-quality care.

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Section: Discussionmentioning

confidence: 81%

Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients

et al. 2019

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“…Obviously, the proposed model needs to be substantiated by additional research projects, and its success also depends on the local availability of the different pulmonary rehabilitation settings. However, this approach is in line with new initiatives, such as COPDnet, where patients with COPD are referred to different care settings with a different treatment modality and intensity after an extensive screening in the secondary care setting …”

Section: Settings For Pulmonary Rehabilitationmentioning

confidence: 88%

Organizational aspects of pulmonary rehabilitation in chronic respiratory diseases

Spruit

Wouters

2019

Respirology

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Adult patients with chronic respiratory diseases may suffer from multiple physical (pulmonary and extrapulmonary), emotional and social features which necessitate a comprehensive, interdisciplinary rehabilitation programme. To date, pulmonary rehabilitation programmes show a lot of variation in setting, content, frequency and duration. Future projects should strive for a standard set of assessment measures to identify patients eligible for pulmonary rehabilitation, taking disease complexity into consideration, which should result in referral to an appropriate rehabilitation setting. Local circumstances may complicate this crucial endeavour.

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“…In an attempt to bridge this gap, we set out to develop an evidence-based model of integrated care for patients with COPD, named the COPDnet integrated care model. 10 The COPDnet integrated care model has the ambition to innovate, simultaneously, both the content of care, ie applying a holistic approach, as well as the organization of care, ie, providing coherent, integrated care within the Dutch health care system. The use of such a model holds a promise to generate better outcomes of care for patients with COPD, as well as an overall reduction in the health care costs.…”

Section: Introductionmentioning

confidence: 99%

“…Principles of the model include the following: 1) an individual care plan based on an assessment of the individual determinants of the burden of disease, 2) which is carried out closely to the natural habitat of the patient, and 3) looks for opportunities to initiate behavioral change, ie reinforcement of patients’ self-management capabilities. Full details of the COPDnet integrated care model can be found in a recently published article by Koolen et al 10 …”

Section: Introductionmentioning

confidence: 99%

Evaluation of the COPDnet integrated care model in patients with COPD: the study protocol

Koolen

Wees²,

Westert³

et al. 2018

COPD

Self Cite

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BackgroundProjections on the future suggest a further rise in the prevalence of patients with COPD, and in COPD related morbidity, mortality, and health care costs worldwide. Given the substantial impact on the individual and on society, it is important to establish a care process that maximizes outcomes in relation to the costs and efforts made. In an attempt to bridge this gap, we set out to develop an evidence-based model of integrated care for patients with COPD, named the COPDnet integrated care model.PurposeThe current study protocol sets out to 1) evaluate the feasibility of employing the COPDnet model in present real-life care within the context of the Dutch health care system, 2) explore the potential health status benefits, and 3) analyze the costs of care of this model.Patients and methodsIn this prospective study, feasibility and health status changes will be evaluated with an experimental before and after study design. The costs of the diagnostic trajectory will be calculated according to a standard economic health care evaluation approach. Furthermore, the feasibility and cost of care studies will comprise both quantitative and qualitative data collection. For the studies on the feasibility and change in health status, all new patients qualifying for shared care by primary and secondary care professionals according to the Dutch Standard of Care for COPD, and patients referred by their general practitioners to one of the COPDnet hospitals will be included. To evaluate the feasibility and costs of care, semi-structured interviews will be held with patients, hospital personnel, health care professionals in the affiliated primary care region, and hospital and primary care group managers.ConclusionsThe COPDnet integrated care model for COPD patients has been designed according to the current insights regarding effective care for patients with a chronic condition in general, and for patients with COPD in particular. It will be evaluated for its feasibility, potential health status benefits, and the costs of care of the diagnostic trajectory in secondary care.

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The COPDnet integrated care model

Cited by 23 publications

References 63 publications

Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients

Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients

Organizational aspects of pulmonary rehabilitation in chronic respiratory diseases

Evaluation of the COPDnet integrated care model in patients with COPD: the study protocol

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