The impact of integrated disease management in high-risk COPD patients in primary care

Ferrone, Madonna; Masciantonio, Marcello G; Malus, Natalie; Stitt, Larry; O'Callahan, Tim; Roberts, Zofe; Johnson, Laura Lee; Samson, Jim; Durocher, Lisa; Ferrari, M. J.; Reilly, Margo; Griffiths, Kelly; Licskai, Christopher

doi:10.1038/s41533-019-0119-9

Cited by 43 publications

(90 citation statements)

References 39 publications

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“…They have grown and matured as a network and are now working to scale and spread their model both to other diseases (such as heart failure) and to a broader geographic region. This growth has been coupled with continued improvements in the health outcomes of patients enrolled in the Lung Health Program (as demonstrated through a control trial conducted by the network) [18]. The network facilitated the implementation of an integrated disease management model (the Lung Health Program), which led to improved patient care and the substantial reduction of rates of acute care services such as ED visits and hospitalization [18].…”

Section: Discussionmentioning

confidence: 99%

“…This growth has been coupled with continued improvements in the health outcomes of patients enrolled in the Lung Health Program (as demonstrated through a control trial conducted by the network) [18]. The network facilitated the implementation of an integrated disease management model (the Lung Health Program), which led to improved patient care and the substantial reduction of rates of acute care services such as ED visits and hospitalization [18]. Overall, the network delivered a dramatically improved quality of life (QoL) when compared with the mean QoL outcome among COPD and lung health patients.…”

Section: Discussionmentioning

confidence: 99%

“…Patient outcome data was comprehensively tracked on their e-tool and regularly discussed at all team meetings. The network boasted about its role in improving the quality of life of more than 2500 patients living in Ontario, Canada suffering from COPD [18]. Participants were proud to explain how these outcomes supported health system performance improvements across the region, seen through the reduction of acute care services including ED visits and hospitalization [28].…”

Section: Demonstrated Improvement Of Patient Outcomesmentioning

confidence: 99%

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Key characteristics and critical junctures for successful Interprofessional networks in healthcare – a case study

Sibbald

Schouten

Sedig

et al. 2020

BMC Health Serv Res

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Background: The use of networks in healthcare has been steadily increasing over the past decade. Healthcare networks reduce fragmented care, support coordination amongst providers and patients, improve health system efficiencies, support better patient care and improve overall satisfaction of both patients and healthcare professionals. There has been little research to date on the implementation, development and use of small localized networks. This paper describes lessons learned from a successful small localized primary care network in Southwestern Ontario that developed and implemented a regional respiratory care program (The ARGI Respiratory Health Program-ARGI is a not-for-profit corporation leading the implementation and evaluation of a respiratory health program. Respiratory therapists (who have a certified respiratory educators designation), care for patients from all seven of the network's FHTs. Patients rostered within the network of FHTs that have been diagnosed with a chronic respiratory disease are referred by their family physicians to the program. The RTs are integrated into the FHTs, and work in a triad along with patients and providers to educate and empower patients in self-management techniques, create exacerbation action plans, and act as a liaison between the patient's care providers. ARGI uses an eTool designed specifically for use by the network to assist care delivery, choosing education topics, and outcome tracking. RTs are hired by ARGI and are contracted to the participating FHTs in the network.). Methods: This study used an exploratory case study approach. Data from four participant groups was collected using focus groups, observations, interviews and document analysis to develop a rich understanding of the multiple perspectives associated with the network. Results: This network's success can be described by four characteristics (growth mindset and quality improvement focus; clear team roles that are strengths-based; shared leadership, shared success; and transparent communication); and five critical junctures (acknowledge a shared need; create a common vision that is flexible and adaptable depending on the context; facilitate empowerment; receive external validation; and demonstrate the impacts and success of their work).

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Demonstrated Improvement Of Patient Outcomesmentioning

confidence: 99%

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Key characteristics and critical junctures for successful Interprofessional networks in healthcare – a case study

Sibbald

Schouten

Sedig

et al. 2020

BMC Health Serv Res

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“…Integrated care programmes have already been demonstrated to reduce the number of readmissions, improve HRQoL and reduce health care utilisation [56][57][58]. As Eileen Collins showed in her talk entitled "Nurses: the spider in the web of integrated respiratory care?…”

Section: Oral Presentation On "Insights Into Rehabilitation and Physimentioning

confidence: 99%

ERS International Congress, Madrid, 2019: highlights from the Allied Respiratory Professionals' Assembly

et al. 2020

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This article provides an overview of outstanding sessions that were (co)organised by the Allied Respiratory Professionals' Assembly during the European Respiratory Society International Congress 2019 in Madrid, Spain. Session content was mainly targeted at allied respiratory professionals such as respiratory physiologists, respiratory physiotherapists and respiratory nurses, and is summarised in this document. Short take-home messages related to pulmonary function testing highlight the importance of quality control. Furthermore, novel findings regarding the assessment of functional status call attention to bodily factors that can affect functional status. Regarding pulmonary rehabilitation, data were presented about the use of equipment and type of exercise training in COPD and lung cancer. Recent developments in physical activity-related research give insight in enablers of physical activity after hospital admission. The importance of integrated respiratory care was also highlighted, with the occupational therapist, nurse, and nutritional and psychological counsellor playing a pivotal role, which relates directly to research in the field of respiratory nursing that formulates the need for more nursing led-interventions in the future. To conclude, this review provides readers with valuable insight into some of the emerging and future areas affecting clinical practice of allied healthcare professionals.

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“…However, studies assessing these interventions show contradictory results, particularly depending on the primary outcome, e.g. quality of life, exacerbations, re-hospitalisations or mortality [1,2,4].…”

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confidence: 99%

Self-management interventions in COPD patients with multimorbidity

Vanfleteren

Fabbri

2019

Eur Respir J

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@ERSpublications Self-management interventions in patients with COPD need to address the complexity of multimorbidity and should include action plans for worsening of both COPD and common comorbidities in order to empower patients to manage their different diseases. http://bit.ly/2nXSCuzCite this article as: Vanfleteren LEGW, Fabbri LM. Self-management interventions in COPD patients with multimorbidity. Eur Respir J 2019; 54: 1901850 [https://doi.org/10.1183/13993003.01850-2019.Self-management interventions in patients with COPD have the goals of motivating, engaging and supporting patients to positively adapt their behaviours and develop skills to better manage their disease. Exacerbation action plans are a key component of COPD self-management interventions [1,2], and self-management interventions are a key component of COPD management [3]. However, studies assessing these interventions show contradictory results, particularly depending on the primary outcome, e.g. quality of life, exacerbations, re-hospitalisations or mortality [1, 2, 4].Self-management interventions, including a COPD exacerbation action plan, are associated with improved health status, as measured by St George's Respiratory Questionnaire (SGRQ), and a lower probability of respiratory-related hospital admissions. Conflicting results on the incidence of exacerbation and mortality have been reported: Exploratory analyses showed a small but significantly higher respiratory-related mortality rate in patients with a high risk of exacerbation [2,5].COPD is almost invariably associated with concomitant chronic diseases, commonly termed comorbidities. A more proper term probably is multimorbidities, i.e. two or more diseases occurring in a person in whom it is difficult to identify an index disease [6]. Exacerbations of COPD should be evaluated in this context. A deterioration of respiratory symptoms in a multimorbid patient who also has COPD demands a differential diagnosis. Viral or bacterial infections, but also heart failure, coronary heart disease, pulmonary embolism and panic attacks, can be equated with an exacerbation of COPD [7].Thus, COPD is just the pulmonary component of multimorbidity, and consequently a patient with COPD should be managed comprehensively for all concomitant chronic diseases that can be identified [3,6,8]. However, a recent elegant and well-designed intervention aimed at comprehensively addressing the complexity of multimorbidity did not improve the quality of life of the patients studied [9].In this issue of the European Respiratory Journal, LENFERINK et al.[10] report the results of an international randomised controlled trial intended to evaluate whether COPD patients with multimorbidities who had been trained in using a patient-tailored multidisease exacerbation action plan (figure 1) had fewer days of COPD exacerbations. Unfortunately, the study was negative for the primary outcome (number of COPD exacerbation days per patient per year) but showed a significant reduction of some relevant predefined secondary outcomes...

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The impact of integrated disease management in high-risk COPD patients in primary care

Cited by 43 publications

References 39 publications

Key characteristics and critical junctures for successful Interprofessional networks in healthcare – a case study

Key characteristics and critical junctures for successful Interprofessional networks in healthcare – a case study

ERS International Congress, Madrid, 2019: highlights from the Allied Respiratory Professionals' Assembly

Self-management interventions in COPD patients with multimorbidity

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