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.
They think beyond smoking
Effective care teams are working as a united front to overcome the preconception that COPD is only about smokers and smoking. As the understanding of COPD grows, it becomes more obvious that success means breaking through the stereo-type and looking beyond smoking. Patients, loved ones, and even more ancillary health care team members like dieticians and home care staff often need to be educated on this.
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.”
Chikita Mann MSN, RN, CCM
Disability RN Case Manager Supervisor
Genex Services, LLC for the State of Georgia
Chikita Mann MSN, RN, CCM
Disability RN Case Manager Supervisor for Genex Services, LLC for the State of Georgia
Vernon Pertelle, RRT
President and CEO of StratiHealth, President and Executive Director of Pulmonary Horizons, Inc.
Keith T. Kanel, MD, MHCM, FACP
Director, The Primary Care Resource Center Project
Clinical Associate Professor of Medicine, University of Pittsburgh
Chris Landon, MD, FAAP, FCCP, CMD
Director of Pediatrics, Ventura County Medical Center, Director of Pediatric Diagnostics Center and CEO, Landon Pediatric Foundation
When there is a concerted effort from the care team to go beyond smoking, new solutions become apparent. Team members begin to identify real causes of exacerbation that have been previously missed—things like pets, flowers, genetics, and other potential triggers. And they can further identify alternative causes of COPD, including second-hand smoke, genetics, and occupations around wood-burning fires. When patients and family members are educated about things beyond smoking, actions that improve care frequently become apparent.
They focus on patient education
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.
They invest in outpatient care
“The home setting is the best place for care,” states Vernon Pertelle. This is a central tenet to many COPD care teams. The panel called out two key technological pillars that are enabling effective outpatient care.
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.
They pay attention to quality of life
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.
2,200 COPD patients were registered in an outreach effort
They learn from other specialties
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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