INSPIRED: Scaling up innovative approaches to COPD care

INSPIRED Joseph Brant Hospital

Tom (patient) gets tips on using his inhaler during a visit from Kathy Theroux, COPD Educator, Joseph Brant Hospital (left) and Jenn Kemp, Respiratory Therapist, VitalAire (right).

Chronic Obstructive Pulmonary Disease (COPD) is one of the most deadly, prevalent and costly chronic diseases. A conservative estimate finds that about 800,000 Canadians live with COPD. Among chronic diseases, COPD is the number one reason for hospitalizations in Canada, accounting for the largest number of inpatient admissions from emergency departments and readmissions.

In 2014-15, CFHI launched INSPIRED Approaches to COPD, a pan-Canadian quality improvement collaborative focused on spreading an innovative model of COPD care. The program supported 19 teams from healthcare organizations across Canada to adapt and adopt INSPIRED.

The program, which was developed by Dr. Graeme Rocker and two colleagues, a respiratory therapist and a spiritual care practitioner, at Capital Health in Halifax (now part of the Nova Scotia Health Authority), supports patients living with moderate-to-severe COPD and their families to transition from the hospital into supported care in the community. It equips patients by providing them with written action plans for managing their disease; phone calls after they are discharged home and at later intervals; at-home self-management education and psychosocial support; and advance care planning when needed. Patients in the program are also given a day-time telephone number to call for support.

A team at Joseph Brant Hospital in Burlington, Ontario participated in the first phase of the collaborative, enrolling approximately 80 patients with COPD in the program.

Lily Spanjevic, a clinical nurse specialist in geriatric medicine and the INSPIRED team lead at Joseph Brant, says they learned many lessons in the first phase of the project, such as needing additional time to work with care providers, patients and their families to enable them to feel comfortable with a changing focus towards self-management with outreach support. Moving forward, she saw the need to build system capacity to adopt and sustain best practices with COPD care.

“We used physician ‘champions’ to speak to their colleagues about the benefits of using action plans, and we set some additional time to discuss with the family their hesitation to use action plans.”

Motivational interviewing and cognitive behavioural therapy approaches also played an important part of “unbreaking learned helplessness.” Many COPD patients blame themselves for their condition and so accept the consequences. Kathy Theroux, a COPD Nurse Educator at Joseph Brant says patients can get around that by learning how to get the most out of life by maintaining an exercise schedule, being active, eating properly and keeping mentally well.

This was true for patients, like Shirley Boag, who was first diagnosed with COPD in 2004. A year before her diagnosis she had quit her 50-year smoking habit, only after an internist told her that her circulation was so bad she could lose her toes. For several years, Boag had colds that lingered, and got out of breath easily on the stairs or walking in snow. Her GP sent her to a respirologist where a breathing test found that she’d lost 50% of her lung function. Today, after 14 years living with COPD, Boag has improved her management of the disease thanks to the INSPIRED program. Although COPD has no cure, Boag says you can learn how to better live with the condition.

“The level of commitment from patients and their families to make the program work was encouraging,” added Spanjevic. “Organizational focus on improving the management of COPD patients and their symptoms helped expedite confirmation of COPD diagnosis, appropriate use of COPD medication, referral to pulmonary rehab, and improvements in end of life care. We believe the combination of the above factors translated to improvements in reducing hospital readmissions and emergency department visits, improved patient and family satisfaction, and reduced hospital costs.”

Following the completion of Phase 1, Joseph Brant saw a 46% reduction in visits to the emergency department and 70% drop in hospital readmissions amounting to an estimated cost savings of up to $855,000, as well as improved quality of life and patient experience for participants.

Given the stellar results, CFHI is supporting the scale up of INSPIRED at Joseph Brant Hospital and the expansion to the Caroline Family Health Team and up to three other primary care organizations serving Burlington, Oakville and Hamilton North.

“From prior experience we know that education for both physician and patients/families about action plans will be key and will need to be reinforced through audits and getting feedback from participants,” said Spanjevic. “As we scale up and increase our team membership, using the communication strategies we learned in Phase 1 will be key to ensure there is clear messaging and to alleviate any misconceptions or barriers early on to enable success of the collaborative.”

By March 2019, enrolment is expected to increase at least three-fold to over 240 people with COPD. As it does, benefits will continue to grow.

An independent analysis showed that expanding the INSPIRED program to reach 5800 patients annually by 2021 would prevent nearly 70,000 visits and 400,000 hospital bed stays. It would also save $688 million in hospital costs over five years. The bottom line? For every $1 invested in the program, $21 in hospital-based costs could be prevented.