The Need for Air

A Review of Chronic Obstructive Pulmonary Disease and the Models of Care Used to Assist with its Management

Case Study

Doreen is a 68-year-old female who presents to her local emergency department via EMS with a 2-day history of worsening shortness of breath. She states that the shortness of breath is worse on exertion, she has a dry cough and reports sleeping in a recliner chair at nights. Denies fever or chills, wheezing, sputum production, chest pain, palpitations, abdominal pain, nausea, vomiting, or diarrhea.

She has a past medical history of hypertension, diabetes mellitus, and chronic obstructive pulmonary disease (COPD).

Social history includes that she is married with three adult children and is a retired nurse. She does not drink alcohol or consume recreational street drugs. She does have a 45-year smoking history (1/2 pack per day) and quite 3 years ago when she was diagnosed with COPD.

She has never been admitted to the hospital before for her chronic disease but after an initial assessment and diagnostic workup in the emergency department with respiratory interventions, it is determined that she will need to be admitted to the hospital. She will require closer monitoring, supplemental oxygen, further diagnostic tests and follow up.

Chronic Obstructive Pulmonary Disease (COPD)

COPD is classified as a chronic and progressive lung disease that causes limitations in airflow (Government of Canada, 2018). The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD Report) (2020) defines COPD as a “preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that us due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung development” (p. 4).

The presented case study is not unique to the many acute care hospitals and primary care practices across this country or globally. In fact, the World Health Organization (WHO) reports a global prevalence of 251 million cases of COPD in 2016 and it accounted for 5% of all global deaths. COPD is the major cause of death and disability worldwide (WHO, 2017).

According to a report from the Canadian Chronic Disease Surveillance System (2018), the case definition of COPD is:

• “A person 35 years and older,

• having at least one visit to a physician with a diagnosis of COPD in the first diagnostic field, or

• one hospital separation with a diagnosis of COPD in any diagnostic field” (p. 24).

In Canada, approximately 20% or 2 million Canadians 35 years and older were living with a COPD diagnosis (data from 2012-2013). The number of Canadians living with COPD has increased by 82% and this increase can be attributed to the aging population. Many people who are diagnosed with COPD are advanced in age and tend to have one or more chronic diseases in addition to COPD (Government of Canada, 2018; Public Health Agency of Canada, 2018).

Figure 1: Prevalence of diagnoses COPD among Canadians aged 35 and older, by age group and sex, Canada, 2011-2012 (Public Health Agency of Canada, 2018). The number one factor contributing to the development and progression of COPD is tobacco smoke, either first (direct smoking), second (indirect smoking), or third (residual smoke) hand smoke (GOLD Report, 2020). Tobacco smoke is not the only risk factor associated with the development of COPD. The WHO (2020) and GOLD Report (2020) detail that genetics and environmental factors such as exposure to air pollution (indoor and outdoor) as well as occupational dust and fumes contribute to the development of COPD.

Patients suffering from COPD tend to see symptoms such as:

• Shortness of breath, especially during physical activities

• Wheezing

• Chronic cough +/- mucus production

• Frequent respiratory infections

• Chest tightness

• Low energy

• Swelling to ankles, feet, or legs

• Unintended weight loss (Mayo Clinic, 2020).

Unfortunately, acute exacerbations of COPD (AECOPD) are a common misfortune for people like Doreen (as presented in the case study). They present to their family physician or in a worst-case scenario their local emergency department with the above symptoms but potentially more serious.

COPD across the Healthcare Continuum

People who experience an AECOPD requiring acute care services place a substantial burden on Canadian emergency departments and acute care hospitals. 2016/17 statistics show that AECOPD was responsible for approximately 90 000 admissions to Canadian hospitals with an average length of stay of 7 days (Flegel & Stanbrook, 2018). It has been found that a person’s health-related quality of life (HRQoL) is negatively impacted as a result of hospital admission (Titova et al., 2015). From the previous blog post What is Health?, we know that “53% of persons with serious disabilities reported that they had an excellent or good quality of life (QoL)” (Albrecht and Devlinger (1999, p. 981). Understanding that HRQoL is a subset of QoL, healthcare providers at all levels of the continuum need to consider the impact that COPD has on people, especially after hospital admission. Strategies, frameworks, policies, and procedures across the healthcare continuum should be followed in order to allow people to avoid hospital admissions and live a high QoL in the presence of chronic disease.

The healthcare continuum consists of:

• Pre-hospital care

• In-hospital care

• Post-hospital care

Figure 2: Healthcare Continuum (CDC, 2017).

In order to assist with the seamless transition of patients through the healthcare continuum, the Government of Ontario endorsed the Patient’s First: Action Plan for Health Care. The principal tenants of the plan promise to put patients first by improving their health care experiences and their health outcomes (Ministry of Health and Long Term Care, 2018).

The plan focuses on 4 key standards:

1. Access: Improve access – providing faster access to the right care.

2. Connect: Connect services – delivering better coordinated and integrated care in the community.

3. Inform: Support people and patients – providing the education, information, and transparency they need to make the right decisions about their health.

4. Protect: Protect our universal public health care system – making evidence-based decisions on value and quality, to sustain the system for generations to come. (Ministry of Health and Long Term Care, 2018).

Figure 3: Patient's First: Action Plan for Healthcare (Taylor & Hein, 2015).

So how does Doreen fit into the healthcare system as someone who is now diagnosed with an AECOPD?

Integrated Comprehensive Care (ICC) Model

Developed in the mid-1990s, the Chronic Care Model (CCM) is one of the first integrated health care models. The CCM “identifies the essential elements of a health care system that encourage high-quality chronic disease care” (Improving Chronic Illness Care, 2011). From the CCM other integrated health care models have been developed to ensure that health services are managed and delivered across the healthcare continuum and as a way to achieve the quadruple aim: better health outcomes, improved patient and provider experience at a lower cost of care (Goodwin, 2016; St. Joseph’s Health System, 2020).

In April 2012, St. Joseph’s Health System (SJHS) developed a patient-centered integrated funding model that was piloted within the Hamilton, Ontario region. The initial pilot was successful in reducing the acute length of stay, emergency department visits, and hospital readmission rates (Guertin et al., 2017; Ahmadi et al., 2020; St. Joseph’s Health System, 2020). From the success of the initial pilot project, ICC 2.0 was implemented and spread into organizations within the Hamilton Niagara Haldimand Brant LHIN.

The Integrated Comprehensive Care (ICC) Program was developed to integrate care across the health continuum, specifically hospital care transitioning to home care. The ICC Program centred on providing care to patients with specific diagnoses by providing a single team and care management model in hospitals and collaborated with home care providers in the community (Guertin et al., 2017). The focus was to “make the patient experience as seamless as possible while utilizing existing resources across the healthcare continuum, to deliver an integrated and comprehensive care experience. ICC is a sustainable, transformational system change enabled by evidence-based integrated service delivery and funding model” (St. Joseph’s Health System, 2020).

What is Integrated Comprehensive Care?

ICC is a model of care that supports patients with the philosophy of “One Team, One Record, One Number to Call, 24/7. ICC is enabled by a co-designed integrated service delivery model and an integrated funding model referred to as One Fund” (St. Joseph’s Health System, 2020; Wheatley, n.d.).

Figure 4: ICC Model - macro (top) and micro (bottom) level (St. Joseph's Health System, 2020; Wheatley, n.d.).

Figure 5: Standard model versus ICC model (Guertin et al., 2017).

Key features of the ICC model include:

1. Integrated Care Coordinator

• Link between hospital specialists and necessary service providers in the community e.g. primary care, home care, specialists

2. The use of mobile technology

• Use of tablets allows the team to communicate with patients in their home environment with the goal of decreasing unnecessary hospital trips

3. Integrated Care Paths

• Standardized care paths across all participating HNHB LHIN hospitals

• Goal is to minimize variation, complications, and unnecessary health care resource utilization

4. A lead homecare agency

5. Strong client engagement

• Supports improved health outcomes and the development of personalized goals

6. High team engagement

• Ensures continuity of care and a high level of collaboration and partnership across the continuum

7. 24/7 availability

• Allows patients to have access to ICC team member with knowledge of their care

8. Timely access to medical expertise

• Ensures adherence to the bundled model (Wheatley, n.d.).

ICC in Action

As previously discussed in the case study, Doreen has been admitted to the hospital with an AECOPD.

How will the ICC model be applied to Doreen’s care continuum?

Pre-hospital

• Doreen is followed by a primary care physician as required

• Her COPD is self-managed well and has never required hospitalization

• She has never been enrolled in the ICC Program before

In-hospital

• Doreen is admitted to the hospital with a diagnosis of COPD

• Her diagnosis prompts the initiation of an evidence-based standardized medical order set specific to COPD

• COPD is part of a Quality Based Procedure (QBP) that allows for high-quality evidence-based care in a standardized way

• Standardized and evidenced-based nursing care pathways will be initiated to ensure the patient meets the Provincial target acute length of stay of 5 days

• Care pathways include the following care considerations:

o Diagnostic and laboratory testing

o Activity

o Nutrition & Elimination

o Teaching

o Patient outcomes

o Interdisciplinary consultations

• The ICC Navigator will be notified to assess the patients' eligibility into the program

• The ICC Navigators role includes:

o Reviewing criteria for patients coming onto the program

o Patient intake into the ICC digital record

o Ensures smooth transition from hospital to home with coordinated discharge planning

o Update ICC interdisciplinary team of new patient details and care pathway schedule

o Will liaison with the hospital interdisciplinary team as needed

o Make appropriate referrals for home care based on the patient's care needs

• Provide the patient with a teaching package that includes standardized information about COPD including education material, goal worksheet, how to access care, COPD management, and an action plan

Post-hospital

• The ICC Navigator will follow up with the patient prior to 30 days and again prior to 60 days

• Approval for an extension in the program can be made based on patient assessment

• The interdisciplinary team follows a standardized visiting schedule in the patient's home for 60 days post hospital admission (e.g. PT, OT, RD, Nurse) (Dalimonte, 2015; Wheatley, n.d.).

Final Thoughts

The ICC model is an evidence based model that is improving the health outcomes for patients like Doreen across the HNHB LHIN. Guertin et al. (2017) concluded in a retrospective observational cohort study that the acute length of stay was shorter in the ICC group (6.47 days) versus that of the non-ICC group (9.55 days). It is also important to note that the ICC program has served more than 20 000 patients with a 98% satisfaction rating (St. Joseph’s Health System, 2020). As more organizations within the province adapt this model of care, the healthcare system will transition to providing a model of care that endeavours to improve patient outcomes, increase patient satisfaction and transform in the way health is provided across the continuum.

References:

Ahmadi, N., Mbuagbaw, L., Finley, C., Agzarian, J., Hanna, W.C., & Shargall, Y. (2020). Impact of the integrated comprehensive car program post-thoracic surgery: A propensity score-matched study. The Journal of Thoracic and Cardiovascular Surgery, In press. https://0-doi-org.aupac.lib.athabascau.ca/10.1016/j.jtcvs.2020.05.095

Albrecht, G.L., & Devlinger, P.J. (1999). The disability paradox: High quality of life against all odds. Social Science & Medicine 48(8), 977–88. https://doi.org/10.1016/S0277-9536(98)00411-0

Centers for Disease Control and Prevention. (2017). Division for heart disease and stroke: About the Cloverdell program. https://www.cdc.gov/dhdsp/programs/about_pcnasp.htm

Dalimonte, T. (2015). Role clarity of ICC team members SJHC. Internal document: Unpublished.

Flengel, K., & Stanbrook, M.B. (2018). To keep patients with COPD out of hospital, look beyond the lungs. CMAJ, 190(48), E1402-E1403. http://doi.org/10.1503/cmaj.181462

Global Initiative for Chronic Obstructive Pulmonary Disease. (2020). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf

Goodwin, N. (2016). Understanding integrated care. International Journal of Integrated Care, 16(4), 6. http://doi.org/10.5334/ijic.2530

Government of Canada. (2018). Data blog: Chronic obstructive pulmonary disease (COPD) in Canada. https://health-infobase.canada.ca/datalab/copd-blog.html

Guertin, J.R., Bowen, J.M., Gosse, C., Blackhouse, G., O’Reilly, D.J., Baltaga, E., Cox, G., Johnson, D., LeBlanc, B., Joncke, J., Pugsley, S., Sivakumaran, R., Wheatley, L., Smith, K., & Tarride, J-E. (2017). Preliminary results of the adoption and application of the integrated comprehensive care bundle care program when treating patients with chronic obstructive pulmonary disease. Canadian Respiratory Journal, 2017. https://doi.org/10.1155/2017/7049483

Improving Chronic Illness Care. (2011). The chronic care model. http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

Mayo Clinic. (2020). COPD. https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679

Ministry of Health and Long Term Care. (2018). About the Excellent Care for All Act. http://www.health.gov.on.ca/en/pro/programs/ecfa/legislation/act.aspx

Public Health Agency of Canada. (2018). Report from the Canadian Chronic Disease Surveillance System: Asthma and chronic obstructive pulmonary disease (COPD) in Canada, 2018. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018/pub-eng.pdf

St. Joseph’s Health System. (2020). Integrated Comprehensive Care. https://sjhs.ca/integratedcare/icc/

Taylor, L. & Hein, G. (2015). Enabling patients first eHealth in Ontario. [PowerPoint slides].

Ministry of Health and Long Term Care. https://docplayer.net/13159485-Enabling-patients-first-ehealth-in-ontario.html

Titova, E., Steinshamn, S., Inderedavik, B., & Hildur Henriksen, A. (2015). Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: A single centre controlled study. Respiratory Research, 16(8). http://doi.org/10.1186/s12931-015-0170-1

World Health Organization. (2017). Chronic Obstructive Pulmonary Disease (COPD). https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)

Wheatley, L. (n.d.). Expanding integrated comprehensive care program across HNHB LHIN for patients with COPD and CHF. Internal document: Unpublished.

Wheatley, L. (n.d). Integrated comprehensive care (ICC). [PowerPoint slides]. Unpublished.