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As the march to value-based care presses on, siloed care teams are no longer sustainable. That’s why more and more leading practices are employing an extended COPD care team. At a recent COPD Insider roundtable, the discussion went beyond how to form an extended care team. The panels compared notes on what were some strategies that are being employed by care teams that are having the highest levels of success.
Here are six strategies the panel identified that effective COPD care teams are employing today.
We are now realizing that it's not just smokers who get COPD. There are also people who are non-smokers, they've never smoked in their lives, and they're also being diagnosed with COPD.”
Disability RN Case Manager Supervisor
Genex Services, LLC for the State of Georgia
Director, The Primary Care Resource Center Project
Clinical Associate Professor of Medicine, University of Pittsburgh
Effective care teams don’t look at patient and family member education as a nice-to-have. They see it as central to success.
Medication and ventilatory support are foundational, but education is just as important. Other benefits to education are that it comes at minimal cost, delivers lasting benefits, and engages the patient in their own care. Don’t overlook the value of extending that education to family members, as they are often able to take simple steps that can make a lasting difference.
Investing in education is a key goal of the entire care team.
Patients need to have the right equipment. This is a detail that successful care teams make sure they get right. Is the supplemental oxygen working for the patient? Do they need non-invasive ventilation? Are these devices properly tailored to the patient’s specific needs?
With shrinking budgets forcing care teams to handle more and more cases, it is just not realistic to be able to monitor COPD patients through home visits. This strategy can leave care teams constantly overwhelmed by their caseload and only dealing with patients who are in crisis.
Care teams that embrace home monitoring are actively working to stay ahead of their COPD cases. They are able to see who is doing well and who is in danger without having to make personal visits.
This is a central tool that many COPD care teams are employing to make outpatient care successful.
The panel was in full agreement that patient quality of life is a powerful lever in the effort to control COPD. Keith Kanel summed it up when he stated: “It is amazing how motivated patients get when you tap into something they really care about.”
COPD patients often suffer from depression or feel that their life is out of their control. This can lead to a lack of motivation for them to participate in their own care, which is not condusive to successful COPD management.
Successful care teams find out what motivates the individual patient. They find out what things will actually improve that person’s quality of life and they focus there. They go beyond the standard goals that the health system wants to see and makes sue each patient is striving towards goals that are important to them as people.
Reducing readmissions is often a central goal to COPD care teams. But the best strategy for reducing readmission is to prevent admission in the first place.
Rather than get their patients after they are discharged from the ED, forward-thinking care teams are starting to embrace outreach and prevention.
Chris Landon explains a recent initiative in which 2,200 COPD patients were registered through an outreach effort, “We launched an outreach program. We went to people’s homes and went to senior health fairs.”
Effective outreach efforts include direct outreach to early-stage COPD patient, as well as education for medical staff who are in positions to identify these patients.
While COPD can often feel all-encompassing, the fact is that many specialties are struggling with similar challenges. Your colleagues in other specialties are often exploring new techniques and methods for patient care—and can be a source of inspiration.
Some COPD care teams are finding that new solutions are right there in their own institutions. They are making an effort to share ideas and learning from the people they pass in the hall every day.
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