Optimizing COPD Collaborative Care in the Ambulatory Setting

1

• Optimizing COPD Collaborative Care in the
  Ambulatory Setting
• Elizabeth Hill RN(EC), MN(ACNP), GNC(C)
• COPD Nurse Practitioner
• Kingston General Hospital

2
Outline

• COPD overview
• Description of collaborative care practice model
  at Kingston General Hospital
• Advantages
• Challenges
• Population at Kingston General Hospital
• Future research

3
Kingston General Hospital
4
Clinical Course of COPD
COPD
Expiratory Flow Limitation Air Trapping Hyperinfla
tion
Exacerbations
Breathlessness
Reduced Exercise Capacity
Poor Health-Related Quality of Life
5
Consequences of COPD exacerbations
Increased mortality with exacerbation hospitaliza
tions
Reduced health-related quality of life
Exacerbations
Increased health resource utilization and
direct costs
Accelerated decline in FEV1
CTS, 2007
6
Comprehensive Management of COPD
Surgery
Surgery
Oxygen
Oxygen
Inhaled corticosteroids/LABA
Inhaled corticosteroids
Pulmonary rehabilitation
Pulmonary rehabilitation
Long
Long-acting bronchodilator(s)
PRN Rapid
Short-acting bronchodilator(s) prn
Smoking cessation/exercise/self
Smoking cessation/exercise/self-management
education
Lung Function
Very Severe
Very Severe
Mild
Mild
Impairment
V
V
MRC Dyspnea Scale
II
II
End of Life Care
Early diagnosis
Prevent/Rx AECOPD
(spirometry)
Follow-up
7
Complexity of COPD

• Comorbidity
• Asthma, bronchiectasis
• Cancer
• Cardiovascular disease
• Diabetes
• Osteoporosis, arthritis
• Depression/anxiety
• Other challenges
• Socioeconomic
• Psychosocial
• Geriatric

8
COPD Patient Flow
KGH COPD Resp Clinic (NP/MD)
KGH COPD Centre (NP)
Respirologists, Clinics, Emergency
Dept., Inpatient services, FP/FHT
9
Virtual team members

• Outside of hospital ambulatory setting
• FP/FHT
• PRIISME pilot-embedded COPD expertise with RT
• Community pharmacist
• Pulmonary rehabilitation (PTs)
• Regional Geriatric Program
• Community Care Access Center
• Oxygen provider

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Advantages of care model

• Improved capacity
• More dynamic response to patient needs
• Improved implementation of evidence based
  practice guidelines in the community
• Care is more comprehensive
• Key issues identified
• COPD management optimized
• Rehabilitation candidates identified
• Self-management education provided
• Exacerbation action plan put in place
• Mobilization of resources
• Follow-up plan in place
• Patient access point established

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Facilitators

• Communication
• Frequent feedback between colleagues
• Frequent discussion about patients and best
  practice
• Common assessment tools/language
• Dictation services and administrative support for
  NP
• Common goals
• Comfort with NP scope expansion

12
Challenges

• Referral from FP needed to move a patient from NP
  care to Respirologist/NP clinic
• Regulation of NP practice reduces efficiency
• PFTs not on list, investigation of
  comorbidities cannot be initiated
• Unable to start inhalers
• Unable to order Prednisone for AECOPD management
• Physicians order required for referral to CCAC
• Database development for information management
• Accessing regional patient information
• Cost of outcomes research

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Patient characteristics

• N266 COPD patients confirmed by spirometry

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Acute events of COPD patients 2 years before
(mean)
0.8 1.0 (0-5, 1)
1.1 1.7 (0-11, 1)
0.1 0.4 (0-3, 0)
1.0 1.6 (0-11, 0)
2.8 3.6 (0-33, 2)
Episodes
Mean time 711 102 (median 730 days)
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Acute lower respiratory tract infection 2 years
before COPD Centre (AECOPD Pneumonia)
1.6 2.1 (0-7, 1)
0.7 0.9 (0-3, 0)
1.4 1.9 (0-11, 1)
0.7 1.1 (0-4, 0)
1.0 1.5 (0-8, 0)
0.4 0.7 (0-4, 0)
Total Hospitalization
0.4 0.9 (0-4, 0)
0.2 0.5 (0-2, 0)
Episodes
Mean time 711 102 (median 730 days)
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Future Research

• Analysis of collected data (N266) to identify
  outcomes related to care model
• AECOPD rates
• ER visits
• Admission to hospital
• Mortality
• Costs associated with care
• Ongoing prospective collection of data for future
  studies

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Summary

• COPD complex respiratory disorder associated with
  multiple comorbidities and progressive disability
  
• Patients often have very complex needs beyond
  COPD
• Interdisciplinary care a necessity
• Comprehensive ambulatory care should reduce
  exacerbations and hospitalization and improve
  morbidity and mortality
• Prospective outcomes research is needed to
  evaluate outcomes associated with
  interdisciplinary care

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Acknowledgements

• Clinical Partner
• Dr.Denis ODonnell, Respirology, Kingston General
  Hospital
• Research Support
• Dr.Denis ODonnell, Respirology, Kingston General
  Hospital
• Dr. Onofre Moran-Mendoza MD, Respirology,
  Kingston General Hospital
• Shawna Froese, Respiratory Investigation Unit,
  Queens University, Kingston Ontario
• Athavudh Deesomehok MD, Respiratory Investigation
  Unit, Queens University