INSPIRED’ Approaches to COPD: Improving Care and Creating Value

Language of instruction: English
Held April 22 – June 26, 2014

Webinar Recordings


Canadians have access to a range of health services, but the transitions between these services are often disjointed. For the elderly or chronically ill, disconnected care can be harmful to their health and costly to the healthcare system. For those with chronic obstructive pulmonary disease (COPD)—a primary cause of emergency room (ER) visits and hospitalizations in Canada—gaps in care are all too obvious.

A typical scenario entails a patient with COPD arriving at the ER severely short of breath, prompting admission and a lengthy hospital stay.  When home again, and without early follow-up, the patient often goes “off the radar” before the cycle inevitably repeats itself, largely due to insufficient community supports leading to repeat admissions. This state of affairs plays out at hospitals across the country, falling short in addressing the medical, psychosocial and spiritual care needs of patients and their families in a patient-centered, evidence-informed and cost-effective way.

This reality has significant impacts on health system resources. Take this example from Ontario, where those living with COPD (about 11 percent of the population) account for one in four of all hospital and ER visits. In fact, landmark work in Ontario shows that people with COPD have a 60 percent higher rate of hospitalization than those without the disease; and 35 per cent of people in Ontario nursing homes and retirement homes are diagnosed with COPD. Translating this to dollars amounts to staggering (and avoidable) healthcare costs—based on recent estimates, Canada spends in excess of $750-million on COPD exacerbations across the nation (and this estimate does not include routine care). New models of care should address these challenges in ways that demonstrate true value for patients, their families and for the healthcare system.

Workshop Scope and Focus

This interactive workshop will focus on key planning, engagement, design and implementation strategies that can help participants learn how to initiate and sustain meaningful improvements to COPD care based on the expressed needs of patients and their family caregivers, as well as most effective use of healthcare resources.

Workshop content is based on the real-life experience and demonstrated successes of INSPIRED, which stands for Implementing a Novel and Supportive Program of Individualized care for patients and families living with REspiratory Disease. It’s a program that improves the patient experience of care and outcomes, while reducing reliance on hospital-based care. The INSPIRED model is a holistic patient- and family-centered approach that addresses the biomedical, psychosocial and spiritual care needs of patients and their families through hospital-home transition services, action plans, patient and family education, coordination of community resources, and advance care planning.

Key principles and elements of this COPD outreach program will be featured, including the associated intervention(s) as well as patient-reported benefits and system efficiency, effectiveness, appropriateness and coordination of care gains. Participating organizations will be equipped to adapt and apply these principles and elements to their own acute and community settings, as well as continue to improve care for patients and families living with COPD.

Learning Objectives

Participants will be able to…

  • Appreciate the importance of patient and family engagement processes to the design, delivery, implementation and evaluation of COPD care, throughout the care experience, including at the end of life
  • Consider the viability of adapting and applying appropriate mechanisms, instruments and metrics that may be used to establish baseline as well as monitor and assess results
  • Consider key principles, processes, pathways and practices that comprise the INSPIRED program – from early intervention and follow up to COPD education, action planning and self-management, coordination of care from hospital to home and more
  • Identify strategies for engaging and communicating with healthcare providers, community partners and decision-makers during program design, delivery, implementation and evaluation phases
Target Audience/ Who should attend
  • Clinicians (e.g., nurses, physicians, respiratory therapists, pharmacists, paramedics) providing COPD care
  • Acute and community care administrators, across the care continuum
  • Quality improvement leaders
  • Patient group representatives
  • Policymakers in health and social services
  • Industry partners and representatives
  • Lung association representatives and other community-based partners


Jennifer Verma image

Jenn Verma, MSc, BJH is the Senior Director of Collaboration for Innovation and Improvement with the Canadian Foundation for Healthcare Improvement in Ottawa, Ontario. She is responsible for managing large-scale health system improvement collaborations, with specific focus on chronic care in Atlantic Canada, managing Triple Aim improvement for high risk-high cost populations across Canada, applying population-based responsibility in Quebec and the upcoming INSPIRED COPD outreach collaborative. Jenn brings expertise in applied health services research and experience in sharing and spreading evidence-informed healthcare solutions. She has developed and led a variety of knowledge exchange products at CFHI, most notably, Mythbusters and the Mythbusters Teaching Resource. Previously, Jennifer worked in the Department of Quality and System Improvement at Eastern Health, the largest regional health authority in Newfoundland and Labrador (NL). She also worked in communications and broadcast journalism as a producer and reporter in Corner Brook, NL (which explains her interest in using storytelling in healthcare). Jenn holds a Master of Science in Medicine in Applied Health Services Research from Memorial University of Newfoundland. She is also a journalism graduate from the University of King’s College in Halifax, Nova Scotia.


Graeme Rocker image

Graeme Rocker, MA, MHSc, DM, FRCP, FRCPC is a Professor of Medicine at Dalhousie University, Halifax, Nova Scotia, Head of the Division of Respirology at Capital Health and is CFHI’s first-ever Clinical Improvement Advisor. He has authored more than 150 original manuscripts and book chapters, bringing extensive clinical and management expertise in the areas of end-of-life care, palliation, dyspnea (breathlessness) in patients with advanced COPD and support for their informal caregivers. Dr. Rocker received the 2009 Roger Bone Award from the American College of Chest Physicians for advances and leadership in end of life care. He is the medical director of the community-based outreach program in Halifax (INSPIRED—Implementing a Novel and Supportive outreach Program of Individualized Care for Patients and Families Living with REspiratory Disease) for patients and families living with advanced COPD. Dr. Rocker works with CFHI as an improvement coach in the Atlantic Healthcare Collaboration Triple Aim Improvement Community and is the lead faculty of the upcoming INSPIRED COPD outreach collaborative.

Catherine Simpson image Catherine Simpson, PhD, MDiv, MA, BA is a founding member of the INSPIRED COPD community outreach team. She is currently responsible for facilitating home-based, psychosocial-spiritual support, and advance care planning for those living with advanced COPD. She also works part-time as a health ethics consultant for the Nova Scotia Health Ethics Network (NSHEN) housed within the Department of Bioethics at Dalhousie University, Halifax, NS. NSHEN's mandate involves working with provincial healthcare organizations to strengthen ethics capacity. Her past experience includes work in the areas of pediatric health promotion, continuing medical education, healthcare chaplaincy, and a stint as coordinator of the Clinical Ethics Consultation component of Capital Health Ethics Support service.

Family Representative:


Denise Nauss, from Halifax, Nova Scotia, brings professional experience ranging from communications and marketing to sales, administration and fashion. In 2009, Denise decided to devote her time to her critically ill parents. Having three daughters, a husband and both parents under one roof was a challenge, however, it was also the most rewarding experience of Denise’s life. Denise and her late mother, Joyce Mason, participated in the INSPIRED program. Denise is pleased to provide her perspective on the INSPIRED program and her experience as a family caregiver. Most recently, Denise and her late mother were featured in a article as well as a Kaiser Permanente patient and family COPD resource video.