Transcript Learning Session 2 Presentation Slides

Shared System of Care (COPD)
Learning Session 2
It will take your breath away
www.pspbc.ca
Case Finding with COPD 6: Table Discussion
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What did you try?
Tell us about your challenges
Tell us about your successes
What surprised you?
What will you try next?
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3
Motivating Patients to Quit Smoking:
Their Lung Age is More Important Than FEV 1
% of smokers
who quit after
receiving test
results
1. Parkes G et al. BMJ 2008;336:598
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Other Action Period Measures
Table Discussion
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Registry Development
Smoking Cessation interventions
COPD Action plans
Specialist Referral
› What did you try?
› Challenges
› Success
› Surprises
› What will you try next?
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Following COPD In the Office
Assessment
Triggers
MRC
Smoking
Vitals
Last Exacerbation
Vaccination
End of life
Referrals
Comorbidities
Treatment
Flareup Plan
Medications & Technique
Monitoring
Chest X-ray
Spirometry
Home oxygen
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Who is at higher risk and needs more follow-up ?
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Frequent exacerbations
Higher MRC score/Dyspnea
Severity of airflow obstruction
On home oxygen
Multiple co-morbidities
Low BMI…
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Spectrum of COPD
Prevention and Awareness
•Promote sustained
stop smoking
services
•Raising
awareness of
early signs and
symptoms
•Early identification
The earliest point at
which airflow
obstruction may be
detected by
spirometry
‘Lower
limits of
normal’
‘Upper
limits of
normal’
Damage
Unaware of Aware of
lung health lung health
No symptoms
Well
• Make links with other
disease areas, e.g. lung
cancer, CHD
Symptoms but
no diagnosis
At-risk
• Roles and
responsibilities of
employers
• Environmental
factors
MILD
stage
MODERATE
stage
SEVERE
stage
VERY SEVERE
stage
With COPD
diagnosis
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Management of stable COPD
Comprehensive Management of COPD
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Classification of Disease Severity in
COPD
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Treatment of stable COPD
GOALS
  Symptoms
  Exacerbations
  Exercise
Beta - agonists
Anticholinergics
Short vs. long-acting
Inhaled corticosteroids
Combination therapies
Antibiotics
Oral prednisone
PDE4 inhibitors
Oxygen
Pulmonary rehabilitation
Smoking cessation
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Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
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1
3
Short-acting Bronchodilators
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Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
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1
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Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
 Stepwise increased therapy
IV (<30%)
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1
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Optimal Pharmacotherapy in COPD
Increasing Disability and Lung Function Impairment
Mild
Moderate
SABA prn
persistent
disability
LAAC + SABA prn
or
LABA + SABA prn
Severe
Infrequent AECOPD
Frequent AECOPD
(< 1/year)
(> 1/year)
LAAC or LABA+ SABA prn
LAAC + ICS/LABA +
SABA prn
persistent
disability
LAAC + LABA + SABA prn
persistent
disability
LAAC + ICS/LABA* +
SABA prn
persistent
disability
LAAC + ICS/LABA +
SABA prn +/- Theophylline
* Inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) combination with the lower
ICS dose i.e. SALM/FP 50/250 µg twice daily
O’Donnell DE, et al. Can Respir J 2007
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Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
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Summary
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Spirometry essential as screening tool in patients at risk
Beware false positive/false negative results
Treatment:
Mild: Short acting BD’s)
Moderate: Long acting BD’s (single or comb)
Severe: Combination BD’s + ICS +Pulmonary Rehabilitation
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Stable COPD: Who should be referred ?
 Dyspnea out of proportion to spirometry
 Young age of onset
 Remote smoking history and disease severity not consistent with
smoking history.
 Rapid deterioration (symptoms or FEV1).
 History of exacerbations.
 Concern re multiple co morbidities
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Case #1
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79yo woman severe SOB
PHx: Overweight (BMI 32), diet controlled DM2, & HTN
Allergy: mild seasonal allergies - rhinorrhea
Smoking: 40 pack. years - quit 20 y ago.
Spirometry: FEV1 78% pred & normal FEV1/FVC ratio. No post BD
change.
 Next step?
2
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Case #1
1.
2.
3.
4.
5.
6.
7.
Explore possibility of heart failure/ischemic heart disease/if acute
onset consider PE.
Could this patient have asthma?
Exam patient and rule out heart failure.
Chest x-ray.
Request testing for reversibility and if normal detailed lung function
obtain lung volume + DLCO
Echocardiogram
Stress test
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COPD case #1
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2.
3.
Spirometry with post bronchodilator assessment showed a
12% improvement consistent with the diagnosis of asthma.
Echocardiogram: Normal
Stress test: No ischemic changes
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Case #1
Diagnosis:
1) Adult onset asthma with likely added de-conditioning and obesity,
2) Initiate low dose inhaled corticosteroids and short acting
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bronchodilators PRN.
3) Advise re immunizations.
4) Provide education about inhaler use and refer for education.
5) Provide a written action plan
Key learning points:
1) Asthma can occur late in life and can occur independently
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or in association with COPD.
 2) Important to identify co existence of asthma in COPD as
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it will effect adjunct therapies such as beta blockers
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Case #2
 68yo man progressive SOB wit a history of a recent exacerbation
requirng a vist to the ED and a course of prednisone and antibiotics.
 PHx: HTN on metoprolol and ramipril.
 Allergy: no seasonal or environmental allergies
 Smoking: 55 pack.years - quit 5 y ago.
 Spirometry: 3 years ago: FEV1 53% pred, FEV1/FVC ratio. No post
BD improvement
 Meds: fluticasone 250 BID, salbutamol 2 inhalations Q4H PRN with
increasing use in the last few weeks.
 Next step?
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Case #2
1.
2.
Clinically this patient has deteriorated with a recent
exacerbation.
What would you do next?
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Case #2
1.
2.
3.
You repeat the spirometry and the FEV1 is now 45% of
predicted.
This patient has severe COPD and a history of
exacerbation and therefore would qualify for the use of a
tiotropium and salmeterol.
Any further deterioration or exacerbation and would use
a combination inhaler and tiotropium.
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Comprehensive Management of COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
 Stepwise increased therapy
IV (<30%)
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COPD Case #2
Question: What reliever medication would you recommend for this
patient?
Key learning point: ipratropium should not be used as a rescue
medication and the patient should be prescribed on a PRN basis
salbutamol.
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Case #3
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60yo woman progressive SOB
PHx: COPD
Allergy: Seasonal allergies years ago
Smoking: 25 pack.years - quit 10 y ago.
Spirometry: 3 years ago: FEV1 54% pred, FEV1/FVC ratio.
Meds: salbutamol and ipratropium bromide PRN and now needing
them up to five times daily.
 Next step?
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Case #3
1.
Repeat spirometry and FEV1 unchanged.
2.
Next steps?
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Case #3
 Add tiotropium bromide, stop ipratropium bromide and continue
salbutamol PRN.
 Six weeks later patient reports some improvement but still short
of breath and has developed peripheral edema?
 What are your concerns now and what would you do?
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2
Case #3
 Clinically there is evidence of congestive heart failure and you
start a diuretic and get an ECHO.
 The ECHO shows a reduced EF of 35% predicted.
 Key learning point:
 HF and severe COPD often co exist and treatment strategies
need to take account of this
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Questions
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Management of severe COPD
GOLD stages (FEV1) I (>80%)
II (50-80%)
III (30-50%)
IV (<30%)
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SEVERE COPD
 Maximize inhaled therapy:
› Combined ICS/ long acting beta-agonists
› Long acting anti cholinergic.
 Additional considerations:
› Ensure patient is taking inhalers correctly if unable to use
spacer and deliver medication correctly consider nebulized
Rx.
› Refer to pulmonary rehabilitation.
› If having frequent exacerbations consider the addition of
azithromycin and/or roflumilast.
› Ensure no untreated co morbidities such as CHF and GERD
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Long term O2 therapy
Indications
Continuous (Grade A evidence)
 Resting ABG pO2 < 55 mmHg
 Resting ABG pO2 55-60 mmHg
› Cor pulmonale
› Hct > 56%
Intermittent (Grade B evidence)
 Exertion: sO2 <87% for > 1 min
 Nocturnal sO2 <88% for > 30% night
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Continuous Home O2
Minimum 20h /day
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Nebulizer treatment in severe COPD
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Beneficial in extremes of age
Coordination not required
Breath-hold not required
Higher dose
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Chronic oral prednisone therapy in COPD
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Chronic oral prednisone therapy in COPD
 There is no evidence base for the regular use of oral prednisone in
COPD.
 In one RCT of prednisone for ARCOPD one group who were left on
prednisone had increased side effects.
 For patients who have frequent AECOPD and continue to exacerbate
despise all the measures outlined above then an N-of-1 trial of
alternate day OCS can be considered.
 Bone density and osteoporosis risk should be regularly reassessed.
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Roflumilast: indication:
1.
2.
Patients with moderate-severe COPD (FEV1 < 50%) ±
chronic bronchitis with frequent ( > 2/year ) exacerbations.
Patients should be advised re the risk of GI side effects.
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Other antibiotics for severe COPD
 Apart fro azithromax there is no evidence that chronic antibiotic therapy
is effective in COPD.
 For exacerbation: rotating antibiotics between classes are
recommended
 A significant minority of COPD patients have co existing bronchiectasis
and in the presence of significant sputum volume and purulence
assessment for atypical TB infection and gram negative pathogens
such as Pseudomonas should be completed.
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COPD Exacerbation
(A.K.A Lung Attack)
COPD Exacerbation
Definition (2 out of 3):
1.
Sustained  Dyspnea
2.
 Cough
3.
 Sputum:  quantity &/or  color
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 fever,  CXR,  constitutional
Risk factors:
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Previous exacerbations *
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GERD
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Reduced FEV1
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Diabetes mellitus.
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C.V. disease
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COPD Exacerbation
Major co$t of COPD
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COPD Exacerbation
(1) No COPD Ex
(2) COPD Ex ER visits no admission
(3) COPD Ex one hospital admission
(4) patients with readmissions.
Soler-Cataluña J J et al. Thorax 2005;60:925-931
Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
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COPD Exacerbations
Causes:
75% infectious
› Virus
› Bacteria
20% environmental
5% Other:
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MI/CHF
Surgery
Aspiration.
Pulmonary embolism (20%
in one study!)
caution - select patient
population
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What is COPD exacerbation ?
Day-to-day variability of a patient with COPD.
Rodriguez-Roisin R Chest 2000;117:398S-401S
©2000 by American College of Chest Physicians
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AECOPD: Prevention Strategies
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COPD Exacerbation
Modifiable risk factors (EFRAM study)
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No influenza vaccination: 28%
No rehabilitation program: 86%
No home O2 (PaO2 < 55mmHg): 28%
Failed inhaler maneuvers: 43%
Current smoker: 26%
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Relapse rate according to each antibiotic group. p < 0.001 for no
antibiotics vs all antibiotics, p < 0.001 for amoxicillin vs all antibiotics, and
p = 0.006 for no antibiotics vs amoxicillin.
Adams S G et al. Chest 2000;117:1345-1352
©2000 by American College of Chest Physicians
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COPD Exacerbations
ANTIBIOTICS
MILD COPD or INFREQUENT
 Older broad spectrum usually enough:
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Septra
Doxycyxline
Cefuroxime
Clarithromycin
SEVERE COPD or FREQUNET
 Stronger antibiotics
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Quinolones (levofloxacin or moxifloxacin)
Cephalospirin (cefixime)
Combination (Macrolide + cephalosporin)
Special consideration: pseudomonas, enterobacter, MRSA
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Lung Attack – Key Learning Point #1
 COPD exacerbation is associated with significant inflammation
and the majority of patients will require OCS.
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Lung attacks: key learning point #2
Always consider other co morbidities such as GERD,CHF,
thromboembolic disease as factors in the AECOPD
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Systemic corticosteroids for acute exacerbations of
COPD
 11 studies (1081 pts.)
 Treatment failure within 30 days with OCS:OR 0.50 (0.36-0.69).
NNTT: 10 pts.
 LOS: -1.22 days (-2.26—0.18).
 Improved FEV1 and less dyspnoea.
 No mortality effect.
 Adverse event: OR 2.33 (4-9).
 Hyperglycemia: OR 4.95 (2.47-9.91)
Cochrane 2009
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Meta-analysis of Efficacy: Systemic Corticosteroids
and Risk for Treatment Failure
Favors Steroid
Favors Placebo
Bullard et al, 1996
Thompson et al, 1996
Davies et al, 1999
Niewoehner et al, 1999
Maltais et al, 2002
Aaron et al, 2003
Pooled summary
(RR, 0.54; 95% CI, 0.41-0.71)
0.1
0.2
0.5
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Relative Risk (95% Confidence Interval)
Contemporary Management of Acute Exacerbations of COPD”, Chest Quon BS et al, 2008 ;
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Pulmonary Rehabilitation
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COPD Exacerbation
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CASES
COPD Exacerbation - Case # 1
60yo woman  SOB and cough x 1 week
PHx:
1. Moderate COPD (FEV1 56%)
2. CAD, recent MI
Smoking: 30 pack years - quit 10 y ago.
Meds 1. Salbutamol/ipratropium bromide 2 puffs QID PRN
2. Metoprolol, ASA, simvastatin
Next steps?
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1
COPD Exacerbation
Case # 1
 Does she have a COPD exacerbation?
›  SOB
›  Cough
›  sputum volume
 Option 1: start antibiotics: which?
 Option 2: Antibiotics + Steroids
 Option 3: close f/u + action plan
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COPD Exacerbation
Case # 1
 Option 2: Antibiotics + Steroids
 Prednisone 50mg x 7days + Septra x 7 days
 Less SOB and reduced sputum volume and purulence.
 What next?
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COPD Exacerbation
Case # 1
Key learning points:
1. Patients may take up to six weeks and longer to return to baseline.
2. Patient has had an AECOPD and need to optimize inhaled therapy with
tiotropium plus or minus a LABA.
3. If symptoms persist consider that the patient may have a component of
asthma and worsening is related to metorpolol or ASA.
4. Note beta blockers are safe in pure COPD and have been associated
with reduced mortality
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COPD Exacerbation
Case # 2
60yo woman:  SOB x 4 week s
Recent 1 week hospital COPD Ex receiving
prednisone, azithromycin, cefuroxime.
PHx:
1. Moderate COPD (FEV1 51%)
2. CAD
3. Diabetes
Meds: 1. Formoterol/budesonide 2 inhalations BID
2. ASA, Ramipril, Simastatin
3. Metformin
Next step?
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COPD Exacerbation
Case # 2
 Does she have COPD exacerbation?
›  SOB
› No Cough
› No sputum
 Option 1: Investigation?
 Option 2: Does her maintenance therapy need to be
adjusted?
 Option 3: Antibiotics + Steroids
 Option 4: Pulmonary rehabilitation referral.
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COPD Exacerbation
Case # 2
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Repeat spirometry and the FEV1 is now 40% of predicted.
Need to optimize inhaled therapy with the addition of tiotropium.
Referral for pulmonary rehabilitation.
Consider co morbidities: CHF,GERD,OSA, Osteoporosis.
Does this patient need home O2? Not likely with an FEV1 of
40% predicted.
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COPD Exacerbation
Case # 3
78yo man
chronic severe SOB + cough
Frequent admissions to hospital in the last
six months
Sputum colonized with MRSA
PHx:
1. Clinical diagnosis of severe COPD (FEV1 not available)
2. CHF
Meds: 1. Salmeterol and fluticasone 500 BID, Tiotropium bromide QD,
salbutamol 2 inhalations Q4H PRN.
2. ASA, Ramipril
Next step?
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COPD Exacerbation
Case # 3
 This patient needs objective assessment of his disease
severity.
 Spirometry shows an FEV1of 30% of predicted.
 This patient has had multiple admissions to hospital and no
objective assessment if his severe disease.
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COPD Exacerbation
Case # 3
 Additional treatment options for severe COPD with frequent ≥
2exacerbations annually ?
1.
2.
3.
4.
5.
6.
Home oxygen assessment
Theophylline or roflumilast
Daily azithromycin
Pulmonary rehabilitation.
Rule out co morbidities that might be contributing
Refer to specialist
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0
COPD Exacerbation
Case # 4
83 y woman
PHx:
chronic severe SOB + cough
monthly admission to hospital
1. Severe COPD (FEV1 33%)
2. CAD previous MI (EF42%)
Meds: 1. salmeterol./fluticasone 500BID, Tiotropium bromide QD,
salbutamol 2 puffs Q4H PRN,
2. ASA, Ramipril, simvastatin, furosemide. lasix
Next step?
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1
COPD Exacerbation
Case # 4
 Obtain sputum C+S:
› Although routine sputum culture is not indicated this lady has
severe COPD and frequent hospitalizations. She is therefore
at risk of Gram negative infection which should be ruled out
as
 Review exacerbating factors at home?
› Smoking (? Second hand)
› Adherence
› Inhaler technique
 How to differentiate CHF vs. COPD?
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COPD Exacerbation: case 4
CHF
COPD
Respond to Nebs
CXR
Pulmonary edema
Usually N
Spirometry
More likely to be N
Abnormal


Dyspnea
Orthopnea
Edema
Responds to diuretic
BNP
Note that with mixed COPD/CHF it maybe
impossible to distinguish primary current problem
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COPD Exacerbations:Case #4
 Key learning points:
 Differentiating the relative contributions of COPD and CHF to
patients symptoms is not easy.
 Careful clinical history taking and clinical examination as well as
judicious assessments including spirometry, BNP and ECHO will
be helpful.
 Therapeutic trials and referral for a specialist assessment maybe
required.
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Conclusion
Severe COPD and exacerbation
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Treatment of COPD is more of an art than science.
Severe COPD:
Maximize inhaled therapy
Ensure patient has received pulmonary rehabilitation.
Supplemental treatments: O2, trial of theophylline, roflumilast ,
oral steroids, chronic antibiotics
COPD exacerbations:
Modifiable risk factors
Increase use of rescue medication.
Provide a written action plan so patient can initiate antibiotics
and prednisone promptly.
Recovery maybe slow. Re assess disease severity and address
co morbidities.
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Who to refer ?
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Symptomatic COPD despite maximal treatment
Subjects with frequent exacerbations.
Concern re multiple co morbidities especially cardiac.
Frequent pneumonias
Dependent on oral corticosteroids.
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Consult Topics
 Answer to specific questions asked by the GP
 Diagnosis
 Treatment recommendations
› Alternate treatment
› Modifications to treatment as the disease progresses
 Responsibilities: roles, when to re-refer patient
 Include an “echo”
 Specific locations/clinics where patient should be sent to receive
further tests or treatment
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Video
 Consult discussion
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Questions
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Exacerbation Plan in
Self-Management Context
Objectives
 Self-management support-a brief summary
 Focus on exacerbation (action-flare up) plans within a selfmanagement context
 Implementing an exacerbation plan-Table discussion
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What is Self-Management?
Self-management relates to the tasks that an individual must
undertake to live well with one or more chronic conditions.
These tasks include gaining confidence to deal with medical
management, role management, and emotional
management.
Adams, Greiner, and Corrigan (2004)
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What is Self-Management Support?
 Self-management support is defined as the systematic
provision of education and supportive interventions by
health care staff to increase patients’ skills and confidence
in managing their health problems, including regular
assessment or progress and problems, goal setting, and
problem-solving support.
Adams et. Al. (2004)
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Self-Management Education:
Reduces Hospitalization
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Benefits of COPD Self Management Education
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The Interaction Sequence
4. Planning
3. Evoking
2. Focusing
1. Engaging
Courtesy of Wm. Miller
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Problem solving
1.
2.
3.
4.
5.
6.
7.
Identify the problem.
List all possible solutions.
Pick one.
Try it for 2 weeks.
If it doesn't’t work, try another.
If that doesn't’t work, find a resource for ideas.
If that doesn't’t work, accept that the problem may not be
solvable now.
Source: Lorig et al, 2001
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Tips for Giving Information
 When?
› They ask for information
› You ask permission to give it
 How?
› Ask what they already know
› Fill in any gaps or gently correct misunderstandings
› Concentrate on key messages
› Use Teach-Back
courtesy of Bill Miller, 2010
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Tips for Giving Advice
 When?
› They ask for information
› You ask permission to give it
› You qualify your advice to emphasize autonomy
 How?
› Offer several suggestions instead of one
› End with a question about something they have thought of on
their own
› Emphasize it’s their choice
courtesy of Bill Miller, 2010
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Health professionals recommendations-context
 Patient’s life context and stage-Broad
 Professional perspective-more focused and point in time - e.g.
Exacerbation plan
 Professional practice approach relates to ‘tasks’ for medical
management
 How to bring the perspectives together for a patient “action
plan”-general and specific-confidence >7/10
 Work over time, know your patient
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Exacerbation Plan
(COPD Flare up
Action Plan)
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Exacerbation Plan – What are we asking of the
patients?
 Understand and accept that they have exacerbations (or even
COPD) that need to be and can be prevented/managed
 Contract between patient and provider
 Monitoring triggers-personal health, environmental
 Recognizing symptoms
 Taking specific actions-many
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Exacerbation Plans in Self-Mgt Context – Table
discussions OR ROLE PLAY
 Given all the things patients have to deal with, how do you
support patients to see the importance of working with an
exacerbation plan?
 How do you increase the confidence level of patients that they
can follow the plan?
 How do you do follow-up and what do you do?
 How do the various providers work together on this with the
patient?
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Advance Care Planning
Advance care planning – healthcare
A process, over time, (can be supported by a patient-focused tool – “My
Voice:
• Assist the patient/family in planning
• Informed decisions throughout trajectory.
• Develop an Advance Care Plan (ACP).
• Communicates plan
• May include a formal Advance Directive (AD).
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Advance Directive (AD)
 Effective September 1, 2011 changes to consent legislation give Advance
Directives (AD) legal status.
 Legally binding on all healthcare providers (including EMT)
 MUST be used by TSDM to guide decisions when patient is incapable of
deciding for self. Only Personal Guardian can override.
 An AD provides written consent or refusal to health care by the adult to a
health care provider, in advance of a decision being required about that health
care.
 AD must be written, signed by a capable adult and witnessed by two witnesses
or one witness who is a lawyer or notary public in good standing with the
Society of Notaries Public. A witness cannot be a person who provides
personal care, health care or financial services to the adult for compensation,
nor the spouse, child, parent, employee or agent of such a person.
 Not to be witnessed by physicians BUT discussion of AD should be part of
Advance Care Planning prior to patient undertaking AD process.
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Who makes your healthcare decisions?
1.
Capable adult (19 yrs).
2.
Personal Guardian (Committee of the person) - court ordered.
3.
Representative named in Representation Agreement.
4.
Temporary Substitute Decision Maker* (TSDM).
a)
Spouse (common law, including same sex)
b)
Adult children (equally ranked)
c)
Parent (equally ranked)
d)
Brother or sister (equally ranked)
e)
Grandparent (equally ranked)
f)
Adult Grandchild (equally ranked)
g)
Another relative by birth or adoption
h)
Close friend of the adult
i)
Person immediately related to the adult by marriage
j)
If no available TSDM, the Public Guardian and Trustee may authorize someone as the TSDM
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When to hold ACP conversations
 Initiate when discussing patient history - patient values and wishes
 Routine follow-up appointments for all adults: “I talk with all my patients
about this and we talked a little about this last year…”
 As part of chronic disease management when discussing care plan:
"This particular illness can have a fairly predictable course…here are
some things you need to think about ahead of time…"
 Following emergency department/hospital admissions: “I understand
you have been in the hospital. What did the doctors say?”
 Document, document, document ….
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Patient wishes
 An Advance Care Plan ensures that the patient's wishes are
respected when the patient is no longer capable of deciding.
 http://www.health.gov.bc.ca/library/publications/year/2012/MyVoi
ce-AdvanceCarePlanningGuide.pdf
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Action Planning
Aim
 To create a shared system of care that improves the quality of
care and experience for patients at risk for and living with COPD
by:
› Identifying early
› Using a team-based approach
› Improving communication
› Improving management
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How will we achieve this aim?
At the GP practice:
 Enhanced identification and diagnosis of COPD
 Appropriate risk stratification based on level of airflow
obstruction and symptoms and exacerbation history – followed
by review of prescriptions
 Appropriate use of evidence-informed treatments for COPD
based on GPAC guidelines
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How will we achieve this aim?
In a shared care environment:
 Implementing more standardized referral and consult letters, and
improving relationships, hand offs and communication between
GPs and specialist physicians
 Developing relationships and care plans amongst
GPs, patients, and community services
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How will we achieve this aim?
Across the continuum
 Supporting patients to quit smoking
 Enhancing patient self-management skills for patients to manage
their condition
 Improving the patient experience with the system of care
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How will we know if we are implementing changes
that will support our goal?
 % of COPD on register having confirmed diagnostic spirometry
 % of COPD patients with an exacerbation plan
 % of smokers on with COPD offered smoking cessation support
 % patients with COPD who have been referred to pulmonary
programs where available
 % of patients with COPD with a coordinated care plan amongst
GPs, specialists, and/or community resources
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How will we know if we are reaching our goal?
 % of registry patients reporting an Emergency Department
visit or having an unplanned GP visit for COPD since their last
appointment.
 % of registry patients reporting a hospital admission for
COPD since their last appointment
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Build on your success, learn from your bumps
Action Period 2
› Continue to screen with COPD 6
 Have you tried using other team members?
› Continue to test processes around smoking cessation
 Have you tried using lung age?
› Continue to populate COPD registry
› Continue to develop and refine GP-Specialist interface
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Try something new
Action Period 2
› Try using/reviewing exacerbation plans with your patients
› Refer patients to Pulmonary Rehab if available
 What else can be done if it is not available?
› Link with Home and Community Care where appropriate
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Action Period Checklist –
Required for AP1 and 2 funding:
 10 Screenings using COPD 6
 5 smoking cessation interventions
 5 COPD exacerbation plans
 Develop a COPD registry
 Discuss consult processes with internist and/or respirologists
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AP - COPD Data Collection sheet
Please fill this form out and return via fax to your local coordinator
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Your opportunity to try something new
 Create your plan with your MOA or other team members
 What is one new thing you can you try in your office
tomorrow?
 What's one new thing you heard here today that you can
try in the next week?
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Evaluations and invoices
 Please fill out our Session Evaluation form
 Fax your Sessional Invoice directly to BCMA
 Do not hesitate to contact the PSP team should you require
module support
 Thank you for participating in this module.
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Appendix
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Storyboard Template
www.pspbc.ca
Our Team
Our team aim statement:
Our team members (photo encouraged)
Our team aim statement:
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Our Results so far
Insert numeric data, include run charts on key measures for the
module.
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Changes Tested or Implemented
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Other changes we couldn’t resist testing
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From all this testing, we have learned
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We are surprised by
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2
Next, we wonder if we should
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Reflections
 What is one idea that you want to try?
 What is one thing you still have questions about?
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For more information
Practice Support Program
115 - 1665 West Broadway
Vancouver, BC V6J 5A4
Tel: 604 736-5551
www.pspbc.ca
www.pspbc.ca