Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes

Abstract

Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient's health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.

Keywords: chronic care model; chronic obstructive pulmonary disease; coordination of care; interdisciplinary care team; patient-centered medical home; self-management.

Figure 1

Key aspects of the patient-centered medical home applied to chronic obstructive pulmonary disease (COPD) care. Abbreviations: ER, emergency room; NP, nurse practitioner; PA, physician assistant; PCP, primary care physician.

Figure 2

Sample patient journey for chronic obstructive pulmonary disease (COPD). Abbreviations: EMR, electronic medical record; GMA, group medical appointment.