Teams

INSPIRED Approaches to COPD: Improving Care and Creating Value

 

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Providence Health Care
  • Executive Sponsor: David Byres (VP, Acute Clinical Programs)
  • Project Lead/ Evaluation and Measurement Lead/ COPD Educator: Jane Burns (Physiotherapist, COPD Outreach Team Lead)
  • Clinical Lead: Don Sin (Head of Respirology at St. Paul’s, Professor, Department of Medicine, UBC)
  • Physician Champion: Stephan van Eeden (Respirologist, Associate Professor, UBC)
  • Administrative Lead: Janis McGladrey (Director, Heart and Lung Centre)

Providence Health Care's initiative aims to build bridges between hospital and community care to help patients with COPD stay as healthy as possible. The team is continuing to reduce both ED visits and hospital admissions, and provide individualized care for COPD patients with complex needs. The initiative catalyzed an assessment of their team’s ability to further improve overall care for patients with chronic diseases; one such improvement includes integrating a Spiritual Care Provider on their team.

Alberta Health Services
  • Executive Co-sponsors: Deb Gordon (VP and Chief Health Operations Officer, Northern Alberta), David Mador (VP and Medical Director, Northern Alberta), Marianne Stewart (Senior Operating Officer, Community and Mental Health, Edmonton Zone), Kathryn Todd (VP, Research, Innovation and analytics)
  • Project Lead: Cori Paul (Manager, Advanced Practice)
  • Evaluation and Measurement Lead: Sherry Albrecht (Program Manager, Planning and Evaluation, Planning and Program Support)
  • COPD Educator: James Prevost (Respiratory Therapist, Professional Practice Lead)
  • Physician Champions: Janice Richman-Eisenstat (Associate Clinical Professor, Pulmonary Division), Dr. Douglas Faulder, Medical Director, Continuing Care, Edmonton Zone, Alberta Health Services, Jasneet Parmar (Medical Lead, Home Living/Continuing Care, Medical Director, Network of Excellence in Seniors’ Health and Wellness, and Associate Professor: Department of Family Medicine, Faculty of Medicine), Jennifer Stickney-Lee (Clinical Assistant Professor, Care of Elderly Division), Warren Ramesh (Respiratory Consultant), Richard Hanelt (Family Physician and Physician Lead of the Good Samaritan Senior’s Clinic), Meena Kalluri (Director, Multidisciplinary ILD Clinic, Assistant Professor), Hubert Kammerer (Co-site Chief), Ingrid De Kock (Physician Lead, Edmonton Zone Palliative Community Consult Team)
  • Clinical Lead: Charlotte Pooler (Clinical Scientist, Continuing Care)
  • Administrative Lead: Carol Anderson (Executive Director, Continuing Care, Edmonton Zone) Douglas Faulder (Medical Director, Continuing Care, Edmonton Zone), Jane Newman (Program Manager, North Networks and Volunteer Resources, Home Living, Continuing Care, Edmunton Zone)
  • Other Team Members: Carmel Montgomery (Clinical Nurse Specialist – Palliative), Colleen Torgunrud (Clinical Ethicist), Dennie Hycha (Director), Teresa Lafrance (Clinical Nurse Educator), Lily Lo (Nurse Practitioner), Barbara Schafer (Nurse Practitioner), Nicole Bonville (Program Manager), Michele Jessop (Manager, CHOICE/Day Programs), Erin Meikle (Practice Development Manager)

Alberta Health Services’ INSPIRED COPD Initiative (ICI) is a quality improvement initiative designed to strengthen Home Living options for clients with a diagnosis of COPD (MRC 4 – 5), thereby enhancing community-based care options, diminishing reliance on hospital use and facilitating appropriate and timely transitions back to the community. Services that will be provided by the ICI advanced practice team include: standardized referral processes, client and caregiver education, individualized COPD Action Plans, opportunities for clients to engage in advance care planning (including tracked Goals of Care conversations), optimized home based pulmonary-rehab, the provision of smoking cessation counseling, expanded primary health care options for clients with advanced COPD in the community, and a focus on building upon the strengths and resiliency of the clients and caregivers that are our partners.

Saskatoon Health Region
  • Executive Sponsor: Maura Davies (CEO)
  • Project Lead: Rick Stene (Manager, Chronic Disease Management - Exercise)
  • Evaluation and Measurement Lead: Donna Goodridge (Professor, College of Medicine)
  • COPD Educator: Shelly Hutchinson (COPD Nurse Clinician)
  • Clinical Lead/Physician Champion: Darcy Marciniuk (Professor of Medicine and Medical Director LiveWell COPD Chronic Disease Management Program)
  • Administrative Lead: Sheila Achilles (Director, Primary Health Care and Chronic Disease Management)
  • Other Team Members: Trent Litzenberger (Director, Pulmonary Rehabilitation), Brittany Kachur (COPD, Nurse Clinican), Ruth Bouvier (COPD Nurse Clinician), Caroline Hinz (COPD Nurse Clinician)

Saskatoon Health Region’s initiative evaluates key outcomes associated with social work for patients with complex psychosocial needs enrolled in the LiveWell with COPD program. By comparing outcomes for patients with complex needs who receive or do not receive the social work intervention, the team will look at improvements as compared to usual care across three key areas: psychosocial adjustment, patient activation, and patient and family satisfaction.

Winnipeg Regional Health Authority
  • Executive Sponsor: Arlene Wilgosh (President & CEO)
  • Project Lead: Craig Hillier (Regional Manager Respiratory Therapy, Acute Care; Site Director Respiratory Therapy/Electrocardiology)
  • Evaluation and Measurement Lead: Kim Dieleman (Manager, Quality, Innovation and Performance Measures)
  • COPD Educator: Olsen Jarvis (Clinical Resource, Respiratory Therapist)
  • Physican Champion: Lawrence Homik (Respirologist, Internal Medicine)
  • Clinical Lead: Ainslie Mihalchuk (Chief Medical Officer and Physician Utilization Officer)
  • Administrative Lead: Laurie Walus (Chief Nursing Officer)
  • Other Team Members: Denise Cann (Social Worker), Debra Vanance (Community Area Director), Carol Deckert (Chronic Disease Specialist), Ola Norrie (Research Associate), Tania Giardini (Clinical Resource Physiotherapist), Marlene Graceffo (Regional Program Director), Lori Embleton (Program Director), Lynne Manikel (Respiratory Home Care Provider), Margarete Moulden (Team Manager, Community Home Care Respiratory Program)

Winnipeg Regional Health Authority’s initiative aims to improve the patient experience and mobilize community services for patients with COPD through integrated partnerships with Concordia Hospital, the Regional Home Care Program, the Regional Palliative Care Program, Community Therapy Services, the Regional Pulmonary Rehabilitation Program, and family physicians. Tools will be implemented to augment and standardize patient self-management support, bridge patient care during the transition to home, and to provide follow-up at home during the transition process. The team will also work with family physicians to implement standardized in-patient COPD order sets and protocols, and individualized action plans inclusive of the use of opioids for dyspnea management.

Bruyère Continuing Care
  • Executive Sponsor: Bernie Blais (President & CEO)
  • Project Lead/Evaluation & Measurement Lead: Jason Nickerson (Clinical Scientist)
  • COPD Educator: Emily McMullen (Respiratory Therapist, Certified Asthma Educator)
  • Physician Champion: Jean Chouinard (Medical Chief, Complex Continuing Care and Long-term Care)
  • Clinical Lead: Debbie Gravelle (Chief Nursing Executive, Senior VP of Hospital Programs)
  • Administrative Lead: Dionne Sinclair (Director, Complex Continuing Care)
  • Other Team Members: Beverley Shea (Bruyère Research Institute), Vivian Welch (Clinical Scientist), Sandra Schmidt (Project Leader, Transforming the Patient Experience, Bruyère Continuing Care), Peter Tanuseputro (Institute for Clinical and Evaluative Sciences, Ottawa Hospital Research Institute), Shauna Adeland (Professional Practice Leader, Social Work, Bruyère Continuing Care)

Bruyère Continuing Care’s initiative aims to develop a comprehensive respiratory program that is interdisciplinary and provides consultation and education to patients and their families. The initiative will focus on implementing a model for smoking cessation, with the goal of systematically identifying smokers, patients with a diagnosis of COPD, and those with risk factors for developing COPD, to ensure that they receive appropriate diagnosis, treatment and follow-up.

Grey Bruce Health Services
  • Executive Sponsor: Maureen Solecki (President & CEO)
  • Project Lead: Jane Wheildon (Manager, Critical Care and Respiratory Therapy)
  • Evaluation and Measurement Lead: Val Fleming (Utilization Management)
  • COPD Educator: Chris MacDougald (Registered Respiratory Therapist)
  • Physician Champions: Marc Newton (Respirologist), Hilli Huff (Physician, Owen Sound Family Health Team)
  • Clinical Lead: Julia Scott (VP, Clinical Service and Chief Nursing Executive)
  • Administrative Leads: Sonja Glass (Chief Quality Officer), Cathy Kelly (Regional Manager of Client Services)
  • Other Team Members: Lynn McDonald (Rapid Response Nurse), Sarah Inglis (Rapid Response Nurse), Shannon Yeo (Hospice Palliative Care Outreach Manager), Robin Dykeman (Manager Medicine and Process Improvement), Graham Fry (Interim Manager Emergency and Dialysis), Suzanne Ste. Croix (Nurse Clinician), Paul Faguy (Executive Director)

Grey Bruce Health Services’ initiative aims to improve patient and family caregiver education and self-management, continuity of care across the hospital-to-home transition, home-based care; effective advance care planning; and reduce reliance on hospital-based care including ED visits, hospital admissions and lengths of stay.

Hamilton Health Sciences
  • Executive Sponsor: Robert MacIsaac (President & CEO)
  • Project Lead: Kelly O’Halloran (Senior Advisor, Quality and Performance Portfolio)
  • Evaluation and Measurement Lead: John You (Division of General Internal Medicine, Department of Medicine, HHS; Associate Professor of Medicine and Clinical Epidemiology & Biostatistics, McMaster University; Member Clinical Advances Through Research and Information Translation (CLARITY); Adjunct Scientist, Institute for Clinical Evaluative Studies)
  • COPD Educator: Stephanie Rotella (Certified COPD Educator, Respiratory Therapist)
  • Physician Champion: Natya Raghavan (Respirology and General Internal Medicine, HHS; Assistant Professor, Department of Medicine, McMaster University)
  • Clinical Lead: William Harper (Chief of Medicine, Hamilton General Hospital)
  • Administrative Lead: Teresa Smith (President, Hamilton General Hospital)
  • Other Team Members: Dilys Haughton (Director, Client Services Operations and Professional Practice Lead, HNHB CCAC), Ruth Kruger (VP, VitalAire Canada)

Hamilton Health Sciences’ (HHS) initiative aims to implement a holistic, proactive, evidenced-based model of care for patients living with moderate to severe COPD while supporting caregivers, reducing reliance on hospital-based care and containing costs. This innovative public-private partnership between HHS, the Hamilton Niagara Haldimand Brant (HNHB) Community Care Access Centre (CCAC) and VitalAire Homecare builds upon previous foundational work related to HHS’ Quality Improvement Plan, COPD Quality Based Procedures and the HNHB Local Health Integration Network (LHIN) COPD Discharge Transitions Bundle. It has also been aligned with work currently underway in the Hamilton West Health Link (HWHL). The initiative specifically aims to reduce the number of emergency department visits, decrease the absolute unplanned readmission rate, and achieve a positive experience with the INSPIRED program for patients admitted to the Hamilton General Hospital (HGH) with a diagnosis of COPD. These outcomes will be achieved through implementation of six focused interventions: 1) Use of the MRC Breathlessness Scale; 2) Use of COPD Action Plan; 3) Patient education and self-management training; 4) Collaboration with Family Practice; 5) Psychosocial and spiritual support to complete ACP and advanced directives; and 6) VitalAire RT assessment of respiratory status and reinforcement of COPD Action Plan.

Joseph Brant Hospital
  • Executive Sponsor: Eric Vandewell (CEO)
  • Project Lead: Melanie Potvin (Director, Acute Care Medicine & Ambulatory, Interim Access & Flow)
  • Evaluation and Measurement Lead: Michelle Goulbourne (Interim Manager, Decision Support)
  • COPD Educator: TBD
  • Physician Champion: Patrick Killorn (Respirologist, Department of Medicine)
  • Clinical Lead: Paul Faulkner (Interim Chief of Staff/Chief of Emergency Department)
  • Administrative Lead: Nancy Labelle (Interim VP Patient Care Services and CNE)
  • Other Team Member: Lily Spanjevic (Clinical Nurse Specialist Geriatrics – Medicine)

Joseph Brant Hospital’s initiative aims to improve the quality and coordination of care for patients with moderate to severe COPD by providing a more holistic, proactive transition from hospital-to-home, and linking patients with community resources. The interdisciplinary team is working towards improving individualized care for patients by implementing self-management education, action plans, psychosocial and spiritual care, and ACP support. Care will take place in conjunction with already established community partners, such as: Community Care Access Centre (CCAC Rapid Response Transitional & Palliative Teams), specialist outpatient visits, primary care, Palliative Care Outreach Team and Health Links as appropriate. Staffing has been secured, community engagement is ongoing and the team looks forward to go live March 2nd.

London Health Sciences Centre
  • Executive Sponsor: Laurie Gould (Chief Clinical and Transformation Officer)
  • Project Lead: Hesham Abdalla (Senior Project Consultant)
  • Evaluation and Measurement Lead: Robin Spence Haffner (Process Improvement Consultant)
  • COPD Educator: Pamela Wilton (Nurse Educator)
  • Physician Champions: Rob McFadden (Medical Director), Donald Farquhar (Professor of Medicine)
  • Clinical Leads: Mary Mueller (Director, Medicine Services), Sherri Lawson (Director, Medicine and Family Medicine)
  • Administrative Lead: Monica Olanski (Manager, Abulatory Care & Family Medical Centres)
  • Other Team Member: Sherry Fletcher (Client Services)

London Health Sciences Centre's (LHSC) initiative is being undertaken in partnership with St. Joseph's Health Care London and the South West Community Care Access Centre and will focus on high-user COPD patients of the Family Medical Centres at LHSC and St. Joseph's, as well as the COPD patients who were admitted to LHSC's two hospital centres from March 2013 – March 2014. The aim of the initiative is to improve outcomes for advanced COPD patients in their transition back to home through enhanced coordination of care across the community. This will include leveraging partnerships to provide care and support in the home to help to better meet patient needs, identify/organize community resources needed to fill gaps in care, and reduce hospital readmission rates. In addition, it will involve developing individualized action plans for each patient.

The Ottawa Hospital
  • Executive Sponsor: Jack Kitts (President and CEO)
  • Project Lead/ COPD Educator: Wendy Laframboise (Nurse Practitioner)
  • Evaluation and Measurement Lead: Peter Henderson (Psychologist)
  • Physician Champion: Jacqueline Sandoz (FRCPC Respirology)
  • Clinical Lead: Shawn Aaron (Physician and Division Head, Respirology)
  • Administrative Lead: Cameron Love (Executive VP and COO), Sherry Daigle (Clinical Manager, Locomotor Stream)
  • Other Team Members: Doug McKim (Medical Director, Respiratory Rehabilitation Services), Claire Ludwig (Director, Program Development & Clinical Care)

The Ottawa Hospital’s initiative aims to improve care quality, effectiveness and efficiency for patients, families and health care providers. With a focus on COPD patients with repeated hospital admissions, the initiative will optimize: self-management education, including a written Action Plan; transition planning from hospital–to-home; the referral process to community resources, such as Pulmonary Rehabilitation, Lung Maintenance and Smoking Cessation Programs, and/or ACP. Additionally, the team will provide post-discharge phone calls, home visits and follow-up support.

University Health Network (UHN)
  • Executive Sponsor: Christopher Paige (VP, Research)
  • Project Co-Lead: James Downar (Attending Staff Physician, Medicine)
  • Evaluation and Measurement Lead/Physician Champion/Project Co-Lead: Deborah Casey (Respirologist, Asthma and Airway Centre, Toronto Western Hospital)
  • COPD Educator: Meeran Manji (RN, Respiratory Educator, Pulmonary Rehabilitation Coordinator)
  • Physician Champions: Howard Abrams (Attending Staff Physician, General Internal Medicine and Director, Centre for Innovation in Complex Care), Kavita Aigu (Palliative Care Physician, Family & Community Medicine)
  • Clinical Lead: Kenneth Chapman (Director, Asthma and Airway Centre, Toronto Western Hospital)
  • Administrative Lead: Kathy Sabo (Executive Lead, Toronto Western Hospital; Senior VP, UHN)
  • Other Team Members: Scott Hines (Respiratory Educator, Asthma and Airway Centre), Emilio Perri (Charge Technologist/Supervisor, Pulmonary Function Lab, Asthma and Airway Centre)

    University Health Network’s initiative aims to reduce ED visits and hospital admissions for patients with COPD, through the establishment of inpatient/outpatient COPD services including: rapid assessment and follow-up after discharge; diagnostic and evaluative testing; comprehensive, interdisciplinary needs assessment including end-of-life planning and symptom management; COPD education; and self-management training and support. The ability to operate this care will be through coordination and collaboration with CCAC, VitalAire homecare therapists, and the Family Health Team to support care transitions and care at home.

    CISSS de la Montérégie-Est (formerly CSSS Pierre-De Saurel)
    • Project Lead: Odette Arsenault (Chronic Disease Manager)
    • Evaluation and Measurement Lead: Christelle Pelbois (Performance Manager)
    • COPD Educator: Jocelyne Trudel (Respiratory Therapist)
    • Physician Champion: Natalie Chevalier (General Practitioner, Medical Coordinator for Chronic Disease)
    • Clinical/Administrative Lead: Sylvie Cusson (Director, Physical Health Programs)
    • Executive Sponsor Martine Bouchard (General Director)
    • Other Team Members: Gérald Désaulniers (Medical Director, Professional Services), Dich Dao Can (Chief of Respirology), Jacques Godin (Respirologist), Rosa Pascual (Coordinator, Risk and Quality/Emergency Measures)

    CISSS de la Montérégie-Est’s initiative aims to provide a continuum of services for patients with COPD by establishing an interdisciplinary early diagnosis program. Individualized action plans to prevent exacerbations in patients with severe COPD will be used to assess whether this contributes to decreased hospital utilization. Other critical components of the initiative include the management of dyspnea attacks in patients in advanced phases of COPD, the integration of a respiratory therapy navigator in the emergency room to coordinate a collaborative, interdisciplinary approach towards users arriving at emergency, post-hospitalization follow-up with a respiratory therapist, and the development of a patient care pathway.

    CISSS du Bas-Saint-Laurent (formerly CSSS Rimouski-Neigette)
    • Executive Sponsor: Luc-André Gagnon (Interim Director General)
    • Project Lead/Evaluation and Measurement Lead: Ginette Dubé (Clinical Nurse)
    • COPD Educator: Stéphanie Denoncourt (Clinical COPD Nurse)
    • Physician Champion: Steeve Goulet (Respirologist)
    • Clinical Lead: Johanne Roy (Coordinator, Public Health and Chronic Disease Network)
    • Administrative Lead: Éric Parent (Director, Physical Health Programs)
    • Other Team Members: Jérôme Bérubé (Kinesiologist), Hélène Thibault (Physiotherapist, Home Care), Sophie Mercier (Respiratory Therapist, Home Care)

    CISSS du Bas-Saint-Laurent’s initiative was prompted by an increase in emergency department (ED) visits by certain COPD clients in recent years. Their initiative aims to improve the continuum of multidisciplinary services offered to patients as well as the tools they need to self-manage their illness. Improving our referral and guidance mechanisms and using action plans for this clientele will be our priorities for ensuring optimal monitoring of patients before, during and after their hospitalization. We hope to strengthen the links between care providers and promote the self-management of illness by the patients.

    Hôpital du Sacré‐Coeur de Montréal
    • Executive Sponsor: Pierre Gfeller (General Director)
    • Project Lead/Administrative Lead : Caroline Riopel (Coordinator, Respiratory Program)
    • Physician Champion/Clinical Lead : François Beaucage (Respirologist)
    • COPD Educator : Esther Cesar (COPD Educator)

    L’Hôpital de Sacré-Cœur de Montréal’s (HSCM) initiative will focus on the efficient use of health services by COPD patients who are identified as large consumers of care. Using an integrated approach in collaboration with care-provider partners from neighboring CSSSs as well as the patient, we hope to be able to develop an inter-institutional plan in order to reduce ED visits and hospital stays. We also hope to systematize referrals to the various programs that are available for COPD clients. The initiative will be carried out at l’Hôpital de Sacré-Coeur, in collaboration with community partners: the Montreal and Laval CSSS network, the regional home-care service (SRSAD) and the Laval regional service for patients with respiratory insufficiency.

    Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ)
    • Executive Sponsor: Michel Delamarre (General Director)
    • Project Lead/Evaluation and Measurement Lead: Isabelle Perreault (Co-Manager, Clinical Respiratory Program)
    • Physician Champion/Administrative Lead: François Maltais (Chief, Respirology)
    • COPD Educator : Christine Ouellet (Clinical Nurse), Nathalie Breault (Clinical Nurse), Benoît Saint-Pierre (Clinical Nurse)
    • Other Team Members: Jean-Marc Fournier (Spiritual Care), Julie Milot (Director, COPD Clinic), Francine Careau (Chief, Service SRSRSD), Claire Langlois (Chief, COPD Clinics), Sébastien Blais (Coordinator, Processes and Performance)

    The Institut Universitaire de Cardiologie et de Pneumologie de Québec’s (IUCPQ) initiative aims to improve patient self-management, psychosocial and spiritual support, provide advance care planning (ACP), and increase collaboration with front-line care providers. The processes for patient referral will be optimized prior to discharge, and the in-home patient follow-up will be standardized to include: needs assessments, patient and family self-management education and tools, and referrals to additional provider resources, as needed. The initiative will be carried out with clients who frequently visit the IUCPQ’s Emergency Department, and those who have been readmitted to hospital within 30 days of discharge. The goal of the project is to reduce the target cohort’s 30-day readmission rate by 7%, thanks to improved, collaborative case management by front-line care providers.

    Horizon Health Network
    • Executive Sponsor: John McGarry (CEO)
    • Project Lead: Josh Scoville (Education Coordinator for Respiratory Therapy, Area 2)
    • Evaluation and Measurement Lead: Pat Lively (Area Director for Electrodiagnostics and Respiratory Therapy)
    • COPD Educator: Angela Taylor (Respiratory Therapist)
    • Physician Champion: Oriano Andreani (Respirology/Internal Medicine)
    • Clinical Lead: Kathy Kowalski (Regional Director of Electrodiagnostics and Respiratory Therapy)
    • Administrative Lead: Dawn Marie Buck (Director, Extra Mural Program and Community Health Centres, Area 2)

    Horizon Health Network’s initiative aims to provide more consistent, continuous patient care for patients and families coping with moderate to severe COPD. The team will focus on formalizing and strengthening communication with the existing Extra Mural Program and Community Health Centers (CHCs) in addition to increasing patient and family education and the use of an individualized action plans.

    Health PEI
    • Executive Sponsor: Richard Wedge (CEO)
    • Project Lead: Carolyn MacPhail (Manager, Chronic Disease Prevention and Management)
    • Evaluation and Measurement Lead: Pat Lush (Health Information Specialist)
    • COPD Educator: Wade Norquay (Respiratory Therapist Supervisor, QEH)
    • Physician Champion: Ayodeji Harris-Eze (Internist, Respirologist, QEH)
    • Clinical Lead: Kennie Martin (Manager, Respiratory Therapy; Provincial Chair, COPD Working Group)
    • Administrative Lead: Deborah Bradley (Executive Director, Community Health; Chair, ICDPM Leadership Committee)
    • Other Team Members: Marilyn Barrett (Director, Primary Care & Chronic Disease), Kim Bustard (Spiritual Care Coordinator)

    Health PEI’s initiative builds on the work underway since 2010, to support the estimated 2,000 people living in PEI with moderate to severe COPD. The objective of the initiative is to build a coordinated, integrated team around advanced COPD patients and their caregivers, ensuring they are empowered with a self-management action plan to prevent and minimize the impact of exacerbations post-hospital discharge. A key component of the initiative is to discuss and determine the best approach to integrate the hospital-based COPD team(s) with the primary care network COPD team(s).

    Nova Scotia Health Authority - Western Zone (South Shore Health)
    • Executive Sponsor: Janet Knox (President & CEO)
    • Project Lead/Evaluation and Measurement Lead: Barb Baker (Project Manager, Health Services)
    • COPD Educator: Janice Dibbin (Certified Respiratory Educator, Asthma/COPD Education Centre)
    • Physician Champion: Daniel DuToit (Internal Medicine Specialist/Respirologist)
    • Clinical Lead: Lynn Farrell (Acting VP, Health Services)
    • Administrative Lead: Marlene Wheatley Downe (Acting Director Health Services, Primary Health & Chronic Disease Management)
    • Other Team Members: Patricia Winfield (Senior Respiratory Therapist), Michelle Tipert (Health Services Manager, ICU & Emergency Department and Acting Health Services Manager, Respiratory Services)

    Nova Scotia Health Authority - Western Zone’s initiative focuses on implementing care pathways for patients who are hospitalized with exacerbations of moderate to severe COPD. It includes implementing clinical care guidelines; applying a coordinated, interdisciplinary approach; and providing health provider and patient education. It will build and strengthen the linkages between primary health care, acute care, home care, and other community-based supports to support patients post-hospitalization. The initiative is currently being piloted at South Shore Regional Hospital before being implemented across the entire District.

    Central Health
    • Executive Sponsor: Rosemarie Goodyear (President & CEO)
    • Project Lead: Valerie Pritchett (Director, Cardiopulmonary Services)
    • Evaluation and Measurement Lead: Natalie Howell (Manager, Program Planning & Evaluation)
    • COPD Educator: Jill Collins (Clinical Lead, Respiratory Therapy – JPMRHC)
    • Physician Champion: Ethelbert Ugwoke (Internist)
    • Clinical Lead: Rajmayur Brahmbhatt (Chief of Staff/Chief of Internal Medicine)
    • Administrative Lead: Sean Tulk (VP Diagnostics and Information Management and COO – CNRHC)
    • Other Team Members: Corinne Shea (Regional Manager, PEDLC), Bev White (Director, Maternal Child and Population Health), Sean Bailey (Director, Health Information Management), Jessica Ruth (Regional Self-management Support and Telehealth Coordinator), Kayla Gillingham (Manager, Home & Community Nursing), Mimie Carroll (Director, Long-term Care & Community Support Services)

    Central Health’s initiative capitalizes on new and existing structures and resources to provide holistic patient-centred care to patients and families with moderate to severe COPD. Continuing the work underway towards implementation of an outreach initiative, the team is creating linkages and a model of care that includes community-based care, community social work, and palliative care. Ultimately, patients and families will be equipped with better self-management skills and other tools to optimize their health and reduce strain on the healthcare system. The initiative will focus on the defined geographical area of communities served by the James Paton Memorial Regional Health Centre.

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