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COPD Service Framework

Collaborative Charter

Improving the care of patients with Chronic Obstructive Pulmonary Disease:

Implementation of the COPD Service Framework

Steering Committee:

Dr. Chris Rauscher, Vancouver Coastal Health Authority

Judy Huska, Northern Health Authority

Shana Ooms, British Columbia Ministry of Health Services

Dr. Treena Chomik, Consultant

Pat Camp, Consultant

Kelly Ablog-Morrant, BC Lung Association

Michael Roch, British Columbian Ministry of Health Services

Connie Sixta, Collaborative Coach

The IH Collaborative Working Group:

Dr. Phil White, General Practitioner

Lorne Yelland, Interior Health

Todd Gale, Interior Health

Dr. Graeme McCauley, Respirologist

Robert Turnbull, Interior Health

Dr. Douglas Rolf, Respirologist

Peter Taylor, COPD Patient

Gerald Barr, COPD Patient

Dr. Erica Bell-Lowther, Interior Health

Jason Kennedy, Interior Health

The Problem

Chronic Obstructive Pulmonary Disease (COPD) has significant personal costs for patients, their families and communities. It is also a burden on the resources of the entire BC health-care system. COPD is an umbrella term used to describe chronic bronchitis and emphysema. It is characterized by progressive, partially progressive airflow limitation, symptoms of dyspnea, cough and sputum production, systemic effects and exacerbations (Chapman, 2003; CTS, 2004). Tobacco smoking is the underlying cause of COPD in 80 to 90 percent of patients (Canadian Institute, 2001).

The prevalence of COPD is increasing throughout much of the world and BC is no exception to the pervasiveness. From 2003 to 2004 in the province, 8,000 new incidences were reported each year (Snapshot, 2005). It is expected that the incidence and burden of COPD will increase within BC as the number and proportion of seniors continues to grow.

There is no cure for COPD; however, significant opportunities exist to improve patient care. These range from primary and secondary prevention to interventions focused on improving patient quality of life through lifestyle modification, pharmacotherapy, exercise training and appropriate advance care planning, including end-of-life care.

The Mission

The COPD service framework is a set of action-oriented and comprehensive recommendations. It sets out the practices for individuals and the health system to provide patient-centered, evidence-based care, using the Expanded Chronic Care Model (ECCM). Recommendations cover the spectrum from targeted prevention of future COPD cases to advance-care planning and end-of-life care.

Within BC, a service framework is defined as a patient-centered approach to improving health outcomes across the conventional boundaries of the health system. It acts as a companion document to clinical practice guidelines. While clinical practice guidelines reinforce the patient-physician relationship, service frameworks extend much further. They address services from all providers across the health continuum, including the contributions from health and community agencies that affect the broader determinants of health. Recognizing this reach, service frameworks are often referred to as “system guidelines.”

They do not attempt to prescribe care; rather, they suggest what services individuals should expect to receive based on optimal pathways of care.

The Interior Health Working Group (IHWG), which authored the COPD Service Framework document, has identified 20 specific recommendations as priority for implementation within the Central Okanagan (Oyama, Lake Country, Kelowna, Westank, Peachland) and Nakusp, BC. The IHWG seeks to carry out a program of change in accordance with the Institute of Health Improvement’s “Learning Model” methodology for health care improvement. (See Methods section – Page 6) This will entail the establishment of physician-led teams, the adoption of innovations in clinical practice, community involvement, care processes and information technology support to enable the collection and sharing of information that is key to improving care outcomes for patients.

The Aim

The aim of this collaborative is to provide optimal care for current and potential COPD patients, in the Central Okanagan and Nakusp, based on the COPD Service Framework. The outcome will be to increase the length and quality of life for COPD patients, improve patient and caregiver satisfaction and optimize the efficiency of health care resources.

Collaborative Goals

During the 10 month duration of the program, physician-led clinical teams in the Central Okanagan and Nakusp will implement a redesigned approach to care based on the top priority recommendations of the COPD Service Framework. It is expected that this will involve primary care physician practices, hospital and community program staff, respiratory therapists, nurses, physiotherapists, dieticians, and community resources.

The ‘minimum data set’ is the priority set of measures and goals that each physician will use to monitor the progress of his/her population of patients with COPD. The priority measures include both outcome and process measures. The minimum data set will allow the physician to effectively measure improvements in patient outcomes, without being to onerous to collect.

Table 1 – Minimum Data Set

|Category |Measure |Target |Data Source |

|Hospital Admissions |Previously hospitalized COPD Registry patients will have a |20% |Pre/Post analysis of |

| |significant reduction in COPD-related admissions compared | |Hospital Admissions data |

| |to a COPD control group matched on age, gender & COPD | |IHA / MOH |

| |hospital admission rate with the same hospital. | | |

|Emergency Room Visits |Previously hospitalized COPD Registry patients will have a |20% |Pre/Post analysis of ER &|

| |significant reduction in COPD related hospital admissions | |Hospital Admissions data |

| |through ER compared to a COPD control group matched on age,| |IHA / MOH |

| |gender & COPD hospital admission rate with the same | | |

| |hospital. | | |

| | | | |

| | | | |

| |Decrease in Emergency Room visits for COPD patients on | | |

| |Registry | |ER data IHA |

| | |50% | |

|Pulmonary Rehabilitation Referral |COPD patients on Registry, who meet criteria (Table 2 on |90% |Flow Sheet |

| |COPD Patient Care Flow Sheet), are referred to Pulmonary | | |

| |Rehabilitation | | |

|Flare up (Exacerbation) Plan in Place|COPD patients on Registry with COPD Flare up (Exacerbation)|90% |Flow Sheet |

| |Plan developed with GP | | |

|Stopped Smoking |COPD patients on Registry who smoke, stop smoking |30% |Flow Sheet |

|Provided Smoking Interventions |COPD patients on Registry who smoke, were provided smoking |85% |Flow Sheet |

| |interventions | | |

|Regular Visits with GP |COPD patients on Registry visit with GP every 3-6 months. |85% |Flow Sheet |

The Methods

Each physician office practice participating in this initiative will:

➢ Identify a specific population of patients with COPD who can be monitored throughout the duration of the initiative (see population at risk section below)

➢ Implement an office-based patient registry during the initiative

➢ Work closely with other health care providers, hospitals, community agencies in the region delivering care to registry patients, to ensure accurate data on care provided is obtained by the physician office practice

➢ Use local measures and a feedback loop to make process changes in the practice

➢ Document, track, and report results of interventions and related population outcomes on a monthly basis.

Participating physician offices and teams will use four key quality improvement strategies to achieve improved outcomes for this priority patient population:

➢ Evidence-based care

Practices will implement the recommendations from approved clinical practice guidelines developed by the Guidelines and Protocols Advisory Committee - Management of Chronic Obstructive Pulmonary Disease and accompanying physician flow sheet.

➢ System change strategy

Practices will use the Performance Improvement Model to test and implement rapid cycle change in health care, with three questions that form the foundation for performance improvement. The P (plan), D (do), S, (study), A (act) cycle provides a methodology for the rapid cycle testing of changes within the office setting (see Figure 1).

Figure 1 – Performance Improvement Model

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➢ Structured learning method

Practices will strive to meet the goals by sharing ideas and knowledge, learning and applying a methodology for organizational change, implementing planned care office-wide and measuring progress in population outcomes – everyone teaches, everyone learns. The methodology consists of several learning workshops where experts and resource people share approaches to system change, followed by action periods. During the action periods, teams make the change in processes or programs that will improve community care for the elderly. Conference calls, monthly reports, support communications and sharing during the action periods (see Figure 2).

Figure 2 – Structured Learning Model

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➢ Evidence-based system change concepts

Practices will implement system re-design for optimal patient outcomes, improved quality of care and professional satisfaction.

Timeframe: The timeline for the COPD Structured Collaborative will be from May 2007 to March 2008, with pre-work activities taking place prior to May 2007.

➢

Collaborative Expectations

The Interior Health COPD Working Group along with the Steering Committee are expected to:

➢ Provide evidence-based information on subject matter, application of that subject matter and methods for process improvement, both during and between Learning Sessions.

➢ Build on what has already been developed in Interior Health and use the best that is available.

➢ Offer coaching to organizations

➢ Provide communication strategies to keep offices connected to the Steering Committee and colleagues during the collaborative.

➢ Provide resources to support team travel to Learning Sessions.

Participating Physician Offices are expected to:

➢ Be open to changing actions and systems in order to improve clinical management and office efficiency.

➢ Perform pre-work activities to prepare for the first Learning Session.

➢ Provide a lead physician who will champion the testing and spread of changes in the practice environment, and will attend all Learning Sessions.

➢ Send a team from the offices to all Learning Sessions.

➢ Provide their team time to devote to testing and implementing changes in the practice.

➢ Test changes that lead to implementation of the Chronic Care Model and produce change in their office practice.

➢ Use an office –based registry to monitor and report population outcomes (COPD measures) on a monthly basis.

➢ Share information with the Collaborative, including details of changes made and data to support these changes, both during and between Learning Sessions.

We will strive to meet the Collaborative goals within the 10 months by sharing ideas and knowledge, learning and applying a methodology for organizational change, implementing a chronic disease management model and measuring progress in population outcomes.

APPENDIX

B.C.'s Expanded Chronic Care Model

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The Expanded Chronic Care Model (ECCM) suggests that by working on both the prevention and treatment ends of the continuum from a broad perspective, health care and other teams represent the best potential for improved health outcomes in the long term. The ECCM recognizes the intrinsic role that social determinants of health play in influencing individual, community and population health. This action-driven model will broaden the focus of practice to work towards health outcomes for individuals, communities and populations.

All areas of action within the ECCM are situated within the community.

1. Build Healthy Public Policy – developing and implementing policies designed to improve population health. This approach combines diverse but complementary approaches, including legislation, fiscal measures, taxation and organizational change – the aim is to make the healthier choice the easier choice.

2. Create Supportive Environments – creating supportive environments entails working to generate living and employment conditions that are safe, stimulating, satisfying and enjoyable. This approach includes strategies to foster conditions for optimal levels of health in social and community environments, such s the provision of safe, accessible and good-quality housing, etc.

3. Strengthen Community Action – working with community groups to set priorities and achieve goals that enhance the health of the community. This approach encourages effective public participation, where health promotion aims to support people in finding their won ways of managing the health of their community.

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