NJC Disease Management Program: Chronic Obstructive Pulmonary Disease (COPD)
Creating Partnerships with Patients and Physicians to Enhance Quality of Life
Comprehensive Assessment and Evaluation
The National Jewish COPD Symptom Action Plan
Access to a COPD Reactive Care Line
Customized Educational Approach
Ongoing Communication with the Treating Physician
Real Case Scenario
Creating Partnerships with Patients and Physicians to Enhance Quality of Life
The Disease Specific Care Managers at National Jewish Medical and Research Center are experiencing great success with patients participating in the nationally recognized Disease Management Program (DMP):COPD. This specialized disease management program went live in July 1998 and since then over 3000 people have participated. This article highlights the successful approach and interventions National Jewish implements on a daily basis. These interventions are designed to empower members to tightly control their condition. This day-to-day health management has lead to an improvement in social activity, quality of life, higher satisfaction with healthcare services and a reduction in medical utilization.
"The first piece of information we share with participants in the DMP: COPD is that their general condition can improve. Since COPD can leave one feeling alienated and alone, some individuals feel they should just give up. Our program offers its participants a chance to control their condition by making several lifestyle changes and getting actively involved with the monitoring and proactive treatment of their condition. The combination of airway management, home and respiratory exercise, proactive symptom management, optimal medication therapy, and smoking cessation facilitates greater independence and a better state of well being," states Linda Endicott, RN, MS nursing supervisor of the DMP:COPD.
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Comprehensive Assessment and Evaluation
During the initial history we evaluate each participant's severity of illness, frequency of symptoms, medication regimen, self-management skills, activity level, psychosocial status and support, lifestyle habits, and overall understanding of their condition. From the very beginning the care managers strive to improve quality. The nurses work with the National Jewish Medical Director to determine if participant's medication regimen is appropriate for their disease severity. Most recently, the Global Initiative for Chronic Obstructive Lung Disease 2001 (National Heart Lung and Blood Institute) report recommends the use of combination therapy for individuals with COPD. All individuals with COPD should have: (1) a "rescue" medication (such as Albuterol) delivered by MDI or nebulizer and (2) an anti-cholinergic medication (such as Ipratropium) or a long-acting Beta 2 Agonist (such as Salmeterol or Formoterol). The care managers continually update patients on new COPD medicines, such as, a once a day anti-cholinergic available later this year.
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The National Jewish COPD Symptom Action Plan
Each participant in the DMP: COPD receive a Symptom Action Plan (SAP). This plan lists each of the symptoms members should pay close attention to on a daily basis. There are four different headings (breathing, thinking, energy, and sputum) included within the SAP. Within each of these categories there is a green, yellow, and red zone. Associated with each of these zones are specific actions. For example, if an individual is more short of breath than usual, he or she is instructed to take their nebulized treatment or rescue inhaler as ordered by their doctor, use pursed lip breathing and relaxation exercises, check their oxygen equipment, etc. The Disease Specific Care Manager reviews the SAP with the participant during each proactive telephonic encounter.
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Access to a COPD Reactive Care Line
All participants have access to a reactive care line 24 hours per day / 7 days per week for support during disease exacerbations or episodes. Members and caregivers are provided with a toll free line to access this reactive care line. Patients who call into the reactive care line receive two follow-up calls from a National Jewish care manager to ensure their respiratory status has returned to a stable state. Copies of all calls are immediately sent to the participant's treating physician.
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Customized Educational Approach
Ongoing education and assessment is provided during a series of proactive telephonic encounters with each participant. A customized education plan is developed for each participant. The educational plan is based upon national standards of care. Individuals are instructed on: (1) the importance of completing their deep breathing exercises and aerobic exercises on a daily basis and the rationale for this; (2) the management of symptoms; (3) strategies to prevent upper respiratory infections; (4) smoking cessation plan and strategies; (5) the purpose and action of COPD medications; and (5) the management of co-morbid conditions or disease states.
In addition to providing education, each participant's condition is evaluated during each encounter. The frequency of days and nights with symptoms, use of nebulizers, urgent physician office visits and utilization events are evaluated during each encounter. The care manager ascertains from the participant the steps they took to manage their early symptoms. Understanding the steps patients are taking in managing their condition will enable the care manager to provide effective education.
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Ongoing Communication with the Treating Physician
Following each encounter with the member/patient, a summary of the findings is faxed to the treating physician. Communication with the member's treating physician is the key to a successful COPD disease management program. Since COPD is a chronic and progressive condition, a patient's regimen will need to change depending upon their symptoms. "Physicians caring for individuals with COPD offer continuous support and treatment. The educational services offered through the DMP:COPD is a nice adjunct to the medical treatment patients receive from their physician. Also, physicians pay close attention to the reports they receive from our program," says Phillip Corsello, MD, the medical director over the National Jewish DMP:COPD program.
The program outcomes are continually evaluated. Each month reports are completed on the following indicators: (1) percentage of patients on appropriate medication therapy following enrollment into the program; (2) changes in days and nights with symptoms following enrollment into the program: (3) hospitalization visits, emergency room visits, unscheduled physician office visits, antibiotic utilization, missed days from work or school; (5) quality of life, and (6) member satisfaction.
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Real Case Scenario
The following is case scenario regarding a patient participating in the DMP:COPD Program. Mr. D.T. is a 68 year-old retired realtor with a 75 pack/year smoking history. His disease severity level upon enrollment into the program was severe. He was on 2L/min of oxygen routinely. He admits to still smoking "on occasion, when I am under stress." Mr. DT has been homebound for two years because of his oxygen system (a Concentrator) and fear of being too far from his nebulizer. An Albuterol inhaler did not afford him the same relief as the nebulizer.
The National Jewish Care Managers worked with Mr. D.T. and his insurance company to change his oxygen to a liquid system with a lightweight and refillable portable tank. After communication with his doctor, he was given a prescription for a Combiventä medication with a spacer. The combination of Ipratropium with Albuterol in a metered dose inhaler afforded him nearly the same relief as medication he was getting in his nebulizer. The nurse provided this patient with detailed instruction on the proper use of a spacer.
DM nurses educated him on the vital importance of exercise and complete smoking cessation in slowing the progression of COPD. He was able to leave the home with his portable Oxygen system and the security of the right medications in his pocket. During the past year, his exercise tolerance has increased from 5-minute walks 3 times a week to 15-20 minute walks 4-5 times a week. He feels comfortable taking short trips outside the home with his wife and grandchild for the first time in years. The patient has reiterated that his change in lifestyle has lead to an increase in Quality of Life. His Oxygen needs at rest have decreased and he mainly uses it during activity and sleep. He also feels prepared to commit to complete smoking cessation at this time.
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