The PRAXIS Nexus The PRAXIS Nexus

Case Managers: Keys to Maximizing COPD Health Outcomes

Posted on July 07, 2016   |   
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COPD case management

This post was written by Kristen Willard, M.S.

In the work being done across the health continuum to support those with COPD and their families, case managers play a pivotal role. On any given day, it is likely that a case manager – whether employed in an acute care or nursing facility, physician practice or other setting – will:

  • Educate COPD patients and families on a variety of crucial topics, including the disease, medications and comorbidities.
  • Help individuals navigate the insurance landscape.
  • Coordinate internal services across the health continuum – from admission to discharge and beyond. This includes interacting with all members of the multidisciplinary team (e.g., MDs, RTs, RNs, RD, PharmD) and maintaining a cohesive patient file.
  • Dialogue with organizations and providers in post-acute settings (e.g., SNFs, home care) to ensure the smoothest possible transitions of care.
  • Conduct follow-up with the patient and his or her family to ensure patient needs are being met and medications and follow-up appointments are maintained.
  • Coordinate with community resources such as faith-based organizations.

We wanted to know from these versatile (and busy!) professionals what their experience has taught them about maximizing outcomes for people with COPD. And so we asked them at a Case Management Society of America conference! Thanks to all of the case managers we met who answered the question: what do you think is the single most important thing we can do improve the lives of individuals with COPD? Here’s what they said.

Proactive care coordination – Pursue preventive care and anticipate issues before they arise, rather than engaging in reactive care (e.g., putting out fires after they have already started).

Personalized plans – Each COPD patient should have a personalized plan of care that was arrived at through shared decision making. The patient and his or her family are central to this process.

Nutrition – Change the way those with COPD eat to be compatible with energy expenditure, to reach and maintain a healthy weight and to maintain the best lung function possible for that patient.

Education – Support patient and family understanding of all facets of living with COPD – including smoking cessation – in an easily understood and accessible way. In particular, ensure ongoing education is provided, once the patient is at home and managing COPD without a care team or provider present.

COPD case management

Empowerment – Empower COPD patients to know more about their disease and to identify the signs of an exacerbation – as well as what steps to take once those signs are recognized. Equip and encourage them to be self-managers of their health!

Engagement – Help those with COPD them to stay engaged in their communities and those activities that are identified by the patient to be important to them.

Team involvement – Ensure everyone in the organization – from health care providers to reception staff – understands the process for COPD patients.

Medications – Medication education and reconciliation are critical to optimizing health outcomes for those with COPD. Double checks and close coordination with clinical pharmacists are essential.

Palliative care and hospice – Have conversations about these two options early in the care relationship. Helping patients to understand the difference between these two approaches as well as an individual person’s wishes for their care progression can bring all parties to the same page and prevent future misunderstandings or pressured conversations.

Psychosocial determinants of health – Early in the process, assess the patient’s psychosocial status and needs. Is depression or anxiety present? Do they have transportation concerns? If they are employed, what supports might they need to continue to be present and successful in their work?

We hope all readers will share their thoughts in the comments below. What do you think is the most essential element to reaching our best COPD outcomes?


 

This page was reviewed on March 3, 2020 by the COPD Foundation Content Review and Evaluation Committee


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  • Agree with Proactive Care Coordination and Personalized Plans being first two, the first as prevention and the second recognizing the diversity that exists case by case for DPOC patients. I would only include in last one customizing exercise routine that is or should be mandatory for all. Our lungs may not regenerate but their function can be greatly improved which in itself translates into greatly improved day to day and less severe exacerbations if and when occur.
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  • I very much Agree with Proactive Care Coordination and Personalized Plans as stated. I especially agree with the psychosocial determinants be done early in the process. In my opinion that it would effect the way the individual would respond to the rest of the care plan. Depression can be very powerful negatively, when not recognized and treated as soon as possible. Anxiety over transportation, money, family also need to be addressed. Thank you.

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  • I just recently stepped into the role as a COPD navigator. I am looking for any kind of advice or recourses that can help me make my program successful. Thanks for your article, it has started me in the right direction. Any other advice will be helpful! Thanks!
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