Chronic Obstructive Pulmonary Disease (COPD), is characterized by persistent airflow limitation that is usually progressive. Symptoms are chronic and progressive dyspnea, cough and sputum production. A primary goal of COPD care is symptom management. COPD is associated with mental and physical comorbidities such as depression, muscle wasting and heart failure (Zhang, 2013).
ElevatingHome Best Practice:
- All patients with COPD should be assessed for risk of hospitalization.
- Both non-pharmacological and pharmacological interventions for COPD should be addressed in a systematic program that is also formally taught to clinical staff.
- Utilize evidence-based disease management program including teaching tools to assure consistent care and patient teaching.
- Focus should be on helping patients develop self-care competencies for those that are able to do so.
Goal: Ensure comprehensive admission and assessment emphasizing respiratory status.
Best Practice Interventions:
- See Table 1: Comprehensive Home Care Approach to COPD
|Table 1: Comprehensive Home Care Approach to COPD|
|Obtain the following information as part of the intake process:
|Start of Care Interventions/Actions|
|Teaching on preventing and managing exacerbations|
Goal: Ensure appropriate pharmacologic interventions and medication management
Best Practice Interventions
- Conduct a thorough medication reconciliation during the SOC and ROC visit.
- Referral to Medical Social Worker (SW) if cost or ability to obtain medications is a problem. Identify distant family members who may be involved &/or willing to cover costs.
- Teach nursing staff need to be extremely cautious of prescribed anticholinergics such as Spiriva if patient has significant asthma component to disease.
- Teach proper use of long acting (LABA’s)verses short acting beta-2 agonists (SABA’s).
- Opioids can be recommended for patients who are poorly controlled.
- Assess understanding of all medication actions and side effects, and on subsequent visits adherence to medication schedule.
- Work with patient to develop self-care behaviors (using teach-back techniques etc) including decisions and plans to incorporate medication taking into daily activities, obtaining initial and refill prescriptions, and managing a change of routine brought about by appointments, travel and other illnesses. Assess for need to obtain devices such as pill boxes to help with medication adherence.
- Assure patient understands which medications should be taken regularly and which are used only as needed to control symptoms Refer to occupational therapy(OT) or speech therapy(ST) for cognitive skills if necessary to help with medication adherence.
- If on multiple inhalers instruct use of inhaler that opens the airways such as short-acting beta-2 agonist (SABA’s) first before an inhaled corticosteroid (ICS) to receive full benefit of both medications. (Hall,2012)
- Determine if patient is prescribed a dry powder inhaler as these depend only on the patient’s inhalation effort to deliver drug.
Patients with severe and very severe COPD should be offered a formal Palliative Care consult if available in the community. Revisit advanced care planning discussions periodically as preferences change particularly as the patient’s health declines. Use a simple, structured approach to facilitate these conversations (See Blueprint for Excellence Modules on Hospice and Palliative Care)
Best Practice Interventions:
- Refer to Palliative Care, or hospice for patients with severe or very severe COPD
- Discuss advanced care planning, palliative care and end-of-life-care options with patients who have severe and very severe COPD including Advanced Directives and POLST.
- Recommend and refer to Hospice care if patient meets Medicare eligibility guidelines. Guidelines include: disabling dyspnea at rest and poorly or unresponsive to bronchodilators, increasing visits to ER or hospitalization for pulmonary disease, hypoxemia at rest on room air, heart failure secondary to COPD, unintentional progressive weight loss and resting tachycardia.
Best Practice Interventions:
- Consider pulmonary rehabilitation post discharge. Pulmonary Rehabilitation has many benefits including improved exercise capacity, reduced intensity of dyspnea, improved quality of life, and reduced number of hospitalizations and days in the hospital.
- Discuss advantages (especially for younger patients) of pulmonary rehabilitation programs post discharge. Make pulmonary rehab referrals/recommendations as needed.
- Review Blueprint for Excellence modules on Preventing Readmissions / Discharge to Community for recommendations on community stay
- CAT – COPD Assessment Test – is an 8-item measure of health status impairment in COPD. Scores range from 0 – 40.
- COPD Control Questionnaire-CCQ is a 10 item self-administered questionnaire developed to measure clinical control in patients with COPD.
- Geriatric Depression Scale (GDS) – – a 15 item scale asking patients to answer yes/no to a series of questions.
- Modified Borg Scale – uses descriptive terms to measure dyspnea with activity.
- Patient Health Questionnaire 2 (PHQ2) – - Utilized in OASIS (M1730) to quickly screen for depression.
- PHQ9 – Expanded version of the Patient Health Questionnaire that probes for specific possible symptoms.
- Respiratory Distress Observation Scale (RDOS) -– used to evaluate dyspnea in patients who cannot self-report using heart rate, respiratory rate, restlessness, accessory muscle use and other indicators. It has been validated for use by trained caregivers, but not yet for use by patient caregivers.
- 6 Minute Walk Test
|Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.|
|By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.|
|Educate payers on opportunity to improve outcomes by more effectively caring for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.|
|Support clinicians to practice at the top of their licenses, train for excellence, and recognize achievement.|