|Table 1: Comprehensive Home Care Approach to COPD
|Obtain the following information as part of the intake process:
Call/speak to patient on day of dc from a facility to ask about:
- H&P and/or hospital discharge summary
- Stage of COPD – Mild, Moderate, Severe, Very Severe
- Conduct full risk assessment (See Blueprint for Excellence Care Initiation) to identify concerns regarding discharge and safety
- Discharge/current medication list
- Ordered treatments and lab tests to be done
- Assess teach-back readiness and any teaching tools used by referral source
- Extent of family involvement; identified caregiver; patient representative.
Recommended Frontloading Schedule
- Who is helping you at home?
- Has your breathing changed since you got home?
- Were all of your prescribed medications obtained? Any questions about them? Was cost an issue if didn’t obtain all of them?
- Do you have a working thermometer in the house?
- Have you used your inhaler/nebulizer since coming home? Any problems? Do you have/use a spacer for your inhaler?
- Do you feel safe &/or do you need a visit today/this evening?
- Provide agency name and contact information and assure 24 hour response to calls.
- SN – Recommend 2- 3 visits in a row - assess, intervene and refocus. Utilize the same RN for visits when possible to assure consistency of care.
- REHAB - 1-3 visits a week starting 1-3 days after initial RN visit
- HHA - to assist with personal care when needed
- MSW - especially if pt unable to afford medications
- 5-7 visits/week 1
- Implement telehealth/telephonic communications 2nd visit if appropriate
Start of Care Interventions/Actions
- Admit with 24 hours
- OASIS, total clinical assessment AND complete respiratory assessment including VS, pain status, SP02, dyspnea assessment using rating scale, standardized tests (BORG,CCQ, CAT), breath sounds, use of accessory muscles, nasal flaring, weight, cough, presence of sputum with change in consistency, color, activity tolerance, mental status, smoking history, oxygen use, ability to use inhaler, nebulizer, manage 02 therapy. Complete respiratory assessment at each visit.
- Assess patient/family concerns and refer to MSW for community resources/psych RN for anxiety and depression.
- Complete medication reconciliation using VERIFY CLARIFY RECONCILE.
- Assess educational needs regarding medications and use of inhalers, nebulizers, 02 equipment.
- Assess immunization status and record in clinical record.
- Check that medications ordered are in home and process exists for obtaining medications as needed including ability to pay for them.
- Introduce Stoplight Method for symptom awareness and self-management
- Provide on-call number, MD contact number and use of 911.
- Assess for tele-health appropriateness
- Refer to PT for exercise, activity tolerance; Refer to OT for energy conservation
- Schedule PCP follow-up appointment within 7 days
Reducing symptoms - Coping strategies for self-management of Shortness of Breath, cough, sputum production
- Ask patients at each visit about tobacco use to ascertain readiness/willingness to make a “quit attempt” to stop smoking.
- Using empathetic communication skills, strongly urge patients to quit.
- If/when patient willing, make referral to local smoking cessation program that includes tobacco dependence counseling and social support.
- Notify PCP of readiness and obtain orders for nicotine replacement products and/or medications such as varenicline, or bupropion SR (sustained release) that help with the physiological addition to tobacco.
- Consider recommending antidepressant to help treat psychological aspect of addiction.
- Counsel patient that because tobacco dependence is a chronic disease, relapse is common, and he/she should not be discouraged
- Teach patient to use a dyspnea rating scale and encourage to log-in levels daily.
- Teach techniques such as pursed lip and diaphragmatic breathing and have patient demonstrate ability to use them to help reduce dyspnea and the anxiety associated with it.
- Proper positioning, in which the patient sits or stands leaning forward with arms supported should be encouraged to help reduce the work of breathing.
- Teach controlled coughing to help clear airways.
- Teach energy conservation techniques and assure patients understanding and ability to use them.
- Work with patient to identify environmental triggers of dyspnea including temperature extremes and exposure to air pollution, chemical fragrances and dust and develop a plan to avoid these triggers.
- Teach clinical signs of a bacterial infection such as increased sputum purulence. and volume and/or dyspnea requiring need for antibiotic treatment.
- Teach secretion clearing strategies such as controlled coughing.
- Some patients may benefit from a trial with an incentive spirometer to help clear airways.
- Explore methods to help improve sleep quality. These may include: (1) go to bed sleepy; (2) adhere to a consistent sleep schedule; (3) adjust timing of medications; (4) avoid sleeping pills; (5) add nighttime oxygen and (6)use of CPAP if sleep apnea is a coexisting factor.
Emotional Health/relaxation techniques: Help patients/caregivers verbalize feelings using empathetic listening skills. (See Blueprint for Excellence Hospice module - Treatment Preferences and Beliefs - for a a discussion of 'artful conversations.'
- Ask patient to keep a log of food and fluid intake and review on each visit.
- Discuss ways to improve intake of protein and calories.
- Help patient plan for small, frequent meals high in protein.
- Avoid gas-forming foods such as beans, and foods in the cabbage family
- High-caloric nutritional supplements may be indicated
- If possible, refer to dietician for help with understanding dietary requirements including fluid requirements/restrictions
- Suggest use of breathing medication one hour before meals.
Exercise: Some form of daily exercise is beneficial for patients with COPD to improve exercise tolerance and reduce dyspnea and fatigue. Work with patients to set exercise goals and overcome barriers. Many patients need to start off very slowly with postural training, simple flexibility and chair exercises.
- Identify healthy coping behaviors such as meditation, listening to music, guided imagery and visualization exercises, breathing and relaxation techniques, to help reduce anxiety.
- Encourage patients to share feelings with family members, friends or health care personnel.
- If patient is positive for depression utilizing the PHQ2 and PHQ 9 or GDS, notify primary care physician (PCP) and make appropriate referrals.
Oxygen therapy and equipment: Long term oxygen therapy (O2) (>15 hrs/day) has been shown to increase survival in patients with severe resting hypoxemia (SPO2 at or below 88%). Medicare coverage guidelines require a SPO2 at or below 88%. Although used to treat exacerbations, CPAP isn’t indicated in the routine, long-term management of COPD.
- Refer to PT and/or OT so an individualized routine can be developed based on the patient’s level of disease and functional capacity.
- Encourage patient to keep an exercise log and review at each visit.
- Suggest new technology such as FITBIT that tracks steps taken and can provide positive reinforcement. (See VNAA Heart Failure Blueprint for details)
- Use the 3 minute walk if 6 minute walk is overwhelming.
Breathing aides – inhalers and nebulizers: Assess proper use of inhalers. Recommend a SPACER prescription from the PCP to assure delivery of full dose of inhaled medications.
- O2 safety should be discussed especially if patient or caregiver smokes.
- Discuss patient O2 requirements with DME company and assure patient/caregiver know how to contact the company when problems with equipment arise.
- Assess need for humidification and request PCP order if needed.
- Teach patient how to clean and maintain O2 equipment.
Self-Monitoring of comorbidities that are common, complicate treatment and impact prognosis.: For Heart Failure management, see the Blueprint for Excellence Module
- Assess proper inhaler technique using teach back method.
- Review proper storage as many inhalers become compromised if exposed to moisture or light.
- Consider need for nebulizer. Nebulizers are recommended if the patient is unable to understand or physically use an inhaler so are often more beneficial for patients who are older or have end-stage disease. Nebulizers may be easier to use for some patients but are more expensive and less portable.
- Teach patient to clean nebulizer after every use and allow to air dry to avoid contamination.
- Teach when to use rescue/controller inhaler and assess understanding using teach-back.
- Hypertension – teach importance of monitoring and maintaining BP goal.
- Osteoporosis – as it is associated with poor health status and prognosis. Discuss avoidance of recurring courses of systemic corticosteroids for COPD exacerbations.
- Anxiety and Depression – screen for and encourage patient to seek treatment if present.
- Infections – patients should monitor for signs and symptoms of infection including increased cough, sputum production, change in color of sputum, and temperature.
- Diabetes – teach importance of keeping Hemoglobin A1c at goal
|Teaching on preventing and managing exacerbations
- Monitor frequency, severity and likely causes of any exacerbations.
- Mark on calendar each time a PRN inhaler is used. Increased use may be first sign of increase in SOB.
- Recognize other signs of exacerbations including worsening dyspnea, chest congestion or discomfort, sleep disturbance and feelings of weakness, fatigue, fear or anxiety.
- Importance of early recognition to initiate prompt treatment and reduce risk of hospitalization, future exacerbations and impaired quality of life.
- Teach staff to be able to identify severity or exacerbations and when a patient can safely be treated at home or should be transferred to the hospital. (See Table below).
- Promote oral hygiene and periodontal health to avoid bacterial infections.
- Increase exercise to help prevent complications of immobility.
- Address nutritional needs for increased protein to decrease risk of infection and monitor weight weekly.
- Assure adequate oxygenation and secretion clearance. Avoid cough suppressants.
- Teach patient to focus on reducing exposure to risk factors
- Avoid persons with respiratory infections.
- Wash hands often to help prevent respiratory infections.
- Avoid gastroesophageal reflux disease.
- Avoid second hand smoke and other environmental pollutants
- Yearly flu vaccination, ideally by October, and pneumonia vaccine
- Pulmonary rehab; Elder services; Private pay services; Continuance of telehealth; Exacerbation prevention; Ongoing determination of tobacco use; Referral to hospice and palliative care when appropriate; Hand off of up-to-date medication list and discharge summary
- Review Blueprint for Excellence modules on Preventing Readmissions / Discharge to Community for recommendations on community stay