Healthcare Organizations Across Canada Collaborate to Transform Care for People with COPD

Alberta Health Services (AHS) Across Canada, an estimated 800,000 Canadians live with chronic obstructive pulmonary disease (COPD), a progressive disease characterized by debilitating breathlessness. This population is among the highest users of hospital care. Of all chronic diseases, COPD is the number one reason for hospitalizations, accounting for the largest number of return visits to emergency departments (EDs) and the highest volume of hospital readmissions. Often, patients end up seeking care in the ED to manage their chronic illnesses because more appropriate care isn’t available in the community. The situation is expected to worsen as one-infour Canadians is set to develop the disease in their lifetime.

From 2014 to 2015, the Canadian Foundation for Healthcare Improvement’s pan-Canadian INSPIRED Approaches to COPD quality improvement collaborative supported 19 healthcare organizations to implement and evaluate a coordinated, proactive approach to improving care for people with COPD and supporting their caregivers. The INSPIRED COPD Outreach Program™ was developed by respirologist Dr. Graeme Rocker and his team at Capital Health (now Nova Scotia Health Authority) in Halifax. CFHI set out to spread this comprehensive approach to COPD care across Canada in partnership with Boehringer Ingelheim (Canada) Ltd.

Participating healthcare teams identified patients who visited the ED or were hospitalized with advanced COPD, and then invited them into a supportive program that provided them with: a written action plan for managing their disease; a phone call after they were discharged home; at-home self-management education and psychosocial support; and advance care planning when needed. Patients in the program were also given a telephone number to call for support.

The CFHI initiative has demonstrated that hospitalizations due to COPD can be decreased by up to 80 percent when patients and their families are supported to better understand the condition and to manage it, when appropriate, at home. Importantly, patients enrolled in the initiative reported greater self-confidence, improved symptom management and a return to daily activities such as climbing stairs, exercising, travelling and returning to work.

The INSPIRED collaborative has proven that we can transform the way chronic illnesses are treated and managed by shifting care, where appropriate, closer to home. An independent analysis concluded that further expanding the program would benefit 14,000 Canadians a year and save $688 million in hospital costs over the coming five years. For every $1 invested in the program, $21 in hospital-based costs could be prevented.