Allow for autonomy

Do not script everything. Allow a team to design their own methods and protocols. When the team’s creativity was unleashed, we saw amazing things happen.”

Keith T. Kanel, MD, MHCM, FACP

Project Director & Chief Medical Officer, University of Pittsburgh

Invest in staff training

 

“We invested in three types of training, which are recommended for any team to replicate.”

Quality improvment icon

Quality improvement

 

“We mapped out our entire process and value streams, to create our own data flow and control charts to track performance”

Disease management icon

Disease management

 

"We partnered with two national organizations, the American Heart Association and the COPD Foundation, who provided on-site training"

Quality improvment icon

Practical training

 

"Didactic University Training programs included simulations of interactions with patients and motivational interviewing"

Make sure the patient is part of your multidisciplinary team

 

A smaller, yet successful program was implemented in Ventura County, California, led by Chris Landon, MD, FFAP, FCCP, CMD, Director of Pediatrics at Ventura County Medical, Pediatric Diagnostics Center, and CEO of the Landon Pediatric Foundation.

 

The program, called The COPD Access to Community Health, employs a multidisciplinary team of behavioral specialists, dieticians and home healthcare nurses. A COPD specialty clinic was also established as part of the initiative.

It’s important to understand where patients are in their lives and on their journeys. If you pay attention, they will contribute valuable information.” 

Chris Landon, MD, FFAP, FCCP, CMD

Director of Pediatrics, Ventura County Medical

Director of Pediatric Diagnostics Center and CEO, Landon Pediatric Foundation

Patients are experts in their own lives, and when given the opportunity, they will tell you what works, what didn’t work in the past and what they believe should be the next step.”

Roberto Benzo, MD, MSc

Motivational Based Health Coaching

While Dr. Landon agrees that collaborating with case managers across disease states is key to better care, he believes that the patient is a critical part of the team. He explains, “It’s important to understand where patients are in their lives and on their journeys. If you pay attention, they will contribute valuable information.”

 

Dr. Landon recalls a time when he discovered his homeless patients had consistently better pulmonary function than those who lived at home or in a care facility. He says, “Turns out that these patients had to bicycle and walk everywhere. Needless to say, this revelation helped us gain support for our pulmonary rehabilitation unit.”

Keep the whole patient in mind

 

Krystal Craddock, COPD case manager at UC Davis, discusses the importance of taking a holistic approach when caring for patients with COPD. She explains, “We’re starting to see more collaboration between COPD care teams and those from other departments and disease states. It’s important that every comorbid condition be addressed, of course, but we also want to remember to see the whole patient.” Craddock insists that she is fortunate her role on the care team as educator enables her to spend time with the patient. “I believe that if we can provide effective care, stay focused on the patient, and empathize with this population, decreasing readmission rates will follow.”

I believe that if we can provide effective care, stay focused on the patient, and empathize with this population, decreasing readmission rates will follow.”

Krystal Craddock, BSRC, RRT-NPS, AEC
COPD Case Manager Department of Respiratory Care at UC Davis Medical Center

Begin discharge planning when the patient is admitted

 

There is perhaps no component of caring for a COPD patient with comorbidities that requires more collaboration across departments and disease states than discharge planning.

 

Chikita Mann says, “The discharge process is fragmented. We are pulling it together within five minutes. The patient will be given various prescriptions and be seen by multiple doctors.” Mann maintains that the discharge process is especially critical with the COPD patient. “You can't do this within five minutes. You can't do it within 10 minutes. A discharge should begin the moment that the patients steps in the door. Until we begin to realize that the discharge process begins when the patient is admitted, we risk providing suboptimal care and that’s not good for the healthcare system or the patient.”

It’s important that we have forums like this to share insights and ideas. To make real improvements in COPD care, we have to remember that collaboration begins with us.” 

Chikita Mann, MSN, RN, CCM Disability RN

Case Manager Supervisor

Genex Services, LLC for the State of Georgia