Central Health tackles care redesign for patients living with COPD


This story is part of a collection featuring improvements from the Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC).

The Challenge

Chronic obstructive pulmonary disease (COPD) is a major health issue in Newfoundland and Labrador. Although only a small percentage of the population live with the disease – 15,000 people, or 4 percent, of the population – COPD is the leading cause of hospital admissions and emergency visits, and has the longest lengths of stay of all chronic conditions in the province. In 2005, Newfoundland and Labrador received a failing grade (F) in the Canadian Lung Association’s national report card for COPD care management. The low mark was due to the province’s high smoking rate – 22 percent of Newfoundlanders smoke – which is a major risk factor for COPD; low public knowledge of COPD; lack of rehabilitation options for people with lung disease; and poor physician adherence to clinical practice guidelines.

Since the CLA report card, the province has taken measures to improve care for people living with COPD. Central Health is leading the province in its efforts to improve care for people who have COPD; the region is working with patients and their families to ensure they have the knowledge and skills they need to better manage their symptoms. They hope to give patients and families better self-management tools in order to optimize their health, as well as reduce the strain that COPD puts on the healthcare system.

The Solution

Working with the Canadian Foundation for Healthcare Improvement through the AHC, Central Health set short-term goals of standardizing and enhancing the quality of COPD care, and improving patients’ self-confidence in their ability to manage their condition. The team created a three step approach to address the needs of patients and their families, and improve the processes of care based on the INSPIRED COPD Outreach Program™ developed at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. These approaches include: standardized patient order sets (standard medication prescriptions), redesign of an existing asthma care centre into a respiratory care centre, and development of an outreach program for patients with advanced COPD.

Central Health also created standardized patient order set and care maps, and educated providers on COPD programs and services to enhance referral and coordination. The team is implementing all of the following interventions:

  1. Optimization of medications and action plan prescription (as per Canadian Thoracic Society Guidelines)
  2. Continuity of care across hospital-to-home transitions
  3. Individualized, coordinated, and proactive care that includes:
    • In-home COPD-related self-management education
    • In-home psychosocial/spiritual support
    • In-home opportunity for advance care planning (ACP)
    • Phone access to team support during working hours
    • Monthly phone follow-up at three, six and twelve months after scheduled home visits
  4. Liaison and partnership building with community and allied healthcare support services
  5. Monitoring and evaluation for quality assurance purposes
  6. Referral of patients to the NL smokers helpline and to community end-of-life care

The Results

The team redesigned the asthma clinic at the James Paton Memorial Regional Health Centre in Gander into an Adult Ambulatory Respiratory Care Centre, which uses a nine month pathway combining onsite medical management with education and self-management support for people with mild to moderate COPD. More than 128 patients have been seen since opening in September 2014, and are now measuring the implementation, accessibility, effectiveness and sustainability of the Centre using the Patient Assessment of Care for Chronic Conditions (PACIC) modified for COPD and drawing on the Care Transitions Measure© (CTM-3), Lung Information Needs Questionnaire (LINQ) and Hopes and Expectations questionnaire for their COPD outreach program.

More recently, Central Health participated in CFHI’s INSPIRED Approaches to COPD: Improving Care and Creating Value collaborative – a 12 month quality improvement collaborative that began in September 2014. Since the first enrollment into the outreach program in January 2015, more than 21 patients have been enrolled.

“Just when we felt hopeless, […] [m]y mom was accepted into the COPD Community outreach program […and] has been given a new lease on life. […] What a dramatic change in her life and ours as her family” – COPD Family Representative

The Spread

After participating in the INSPIRED Approaches to COPD: Improving Care and Creating Value collaborative, the team reports significant change for COPD care in their organization. The team also shared results at several conferences and fora, including the 2013 National Health Leadership Conference (NHLC) alongside other Atlantic Healthcare Collaboration teams and the 2015 Primary Healthcare Partnership forum (Prifor) hosted by Memorial University in Newfoundland and Labrador.

Valerie-Pritchett-125Valerie Pritchett
Director, Cardiopulmonary Services
Central Health