The Nuts and Bolts of

the INSPIRED COPD

Outreach ProgramDalhousie Fall Refresher

2018 Lesley MacGregor MN NP CRE – Nurse Practitioner

John Cushing BSc RRT CRE – Respiratory Therapist

INSPIRED COPD Outreach Program

Objectives:

COPD: Our Current Reality

Overview of the INSPIRED COPD Outreach Program – Patient Profile

Describe home visits by COPD educator/RRT

Discuss Additional Interventions and Follow up Phone calls

Overview of Advanced Care Planning

Overview of the Nurse Practitioner Role

Canadian Thoracic Guidelines for management of COPD

Brief overview of Dyspnea management with Opioids.

Lessons Learned…

COPD: Our Current Reality

4th leading cause of death

1:4 Canadians >35 years will develop COPD

Among chronic diseases, COPD is the most common cause of admissions/re-admissions

• Suffer from refractory dyspnea (up to 50%)

• Relief from dyspnea a top priority; plan of care at discharge1

• Have symptom burden similar to or worse than patients with

advanced lung cancer2

1. Rocker GM, Dodek PE, Heyland DK. Can Respir J 2008;15:249-54

2. Gore et al., Thorax 2000

Many patients with advanced COPD:

2020: 3rd leading cause of death(already 3rd in United States)

COPD: Our Current Reality

Many COPD patients are advanced in age and often

have one or more other chronic diseases or

conditions in addition to COPD.

This co-morbidity means more intensive

requirements will be placed on the health care

system in both time and resources, as several

diseases or conditions need to be managed

simultaneously.

This adds to the burden and costs of caring for

COPD patients.

INSPIRED Patient Profile

Marjorie K.

66 year old female

Severe COPD FEV1 20%

On home O2 2-3 lts

Hx of numerous AECOPD and hospital admission

Comorbidities: Colitis, OA, CHF, Anxiety, Thyroidectomy

Home bound, socially isolated due to dyspnea

Extreme difficulty getting out to medical apts

INSPIRED COPD Outreach Program

Overview/Patient Experience

INSPIRED COPD Outreach ProgramTM

Since 2010/11 > 750 patients with advanced

COPD enrolled in HRM

Supports patients living and

dying with advanced COPD by:

minimizing time in hospital

keeping patients at home

where requested and where

possible

Provides better care, better

outcomes and value+++ for

money

INSPIRED COPD Outreach

Program Team

An inter-disciplinary team

Medical Director

Program Coordinator

Nurse Practitioner – Certified Respiratory Educator

Respiratory Therapists – Certified Respiratory Educators

Advance Care Planners

Social Worker

INSPIRED COPD Outreach

Program

The INSPIRED COPD Outreach Program brings together a team of professionals to provide education and support to people with COPD and their families in their homes to help them cope better with COPD.

Home-based education

A “COPD Action Plan” to help manage COPD and its acute flare-ups so that you can treat infections early and avoid trips to the Emergency Department.

Medication Optimization/Immunization

Dyspnea management

Help with navigating the healthcare system and gaining access to programs/services that may be helpful to you.

An opportunity to discuss advance care planning.

Certified Respiratory

Educator

COPD/Asthma Education

Chronic disease management/Principles of adult

learning

Credential information through CNRC

http://cnrchome.net/ Continuing education encouraged and supported

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http://cnrchome.net/

INSPIRED COPD Outreach Program

Eligibility

Confirmed, pending or suspected diagnosis of COPD

Live in Central Zone

Not in long term care or residential care facility

In the past year >1 visit to ED for AECOPD or > or equal to 1 admission to hospital for AECOPD

Is willing to be referred

Referral Form

9

Referral Sources

Daily ED list - pts with COPD/pneumonia/SOB NYD

EDIS* system at QEII

Referrals from in-patient units

RT initiated or from staff on unit

Referrals from Respirology or community

Err on side of acceptance or at least check it out

*emergency department information systems

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Intake

Program coordinator confirms COPD

diagnosis/history (Spirometry results?)

Meets patient in hospital if possible –

introduces program

Patient/family brochure*

Intake phone interview is conducted by

Advance Care Planner and/or Social Worker

to overview program and identify goals

Patient is assigned to either a RRT or the NP

depending on medical complexity. 14

COPD Educator Visit 1

Explain program – consent signed

Begin discussion re: COPD assess knowledge of disease

Introduce COPD education materials

Introduce Action Plan signs and symptoms of impending AECOPD

• Strategies to manage dyspnea, energy conservation, smoking cessation, exercise, etc.

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Action Plan

Plan of action for exacerbations

Canadian Respiratory Guidelines

From patient chart: Allergies and current

medications

Nurse Practitioner completes Action Plan and gives

to RRT or provides to patient directly

Provided to patient on the first/second visit

Is patient able to use it appropriately (Y/N)

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COPD Action Plan

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Breathlessness

Management

• Hand-held fan

• PLB*

• Energy conservation

• Inhaled medications

• Coping with panic/anxiety

• Avoid triggers

• Others….?

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*pursed lip breathing

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COPD Educator Visit 2

Continuation of COPD self-management

education

Within 1-2 weeks of Visit 1

Follow-up on any issues identified in Visit 1

Additional visits/follow-up plan

Ensuing team visits - coping/ACP

Phone follow-ups (can be home visit)

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Additional Interventions

Opioids for dyspnea management

Palliative Care consults

Continuing Care referrals (home supports,

home O2, etc.)

Special Patient Program enrollment with

EHS

EHS-O2 alert cards/Venturi masks

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• Rapid adoption SAFE SATS range

(88-92%) (BTS 2008, updates,

GOLD 2017 (50 years after

Campbell)

• Education of patients and health

care workers

• Supply AT RISK patients with Venturi

masks and “Oxygen Alert” cards

• Flag patients AT RISK in EHS/ED

systems

• Re-install Venturi masks part of EHS

equipment inventory

Reducing risk of oxygen-

induced hypercapnia

Additional Interventions

Allied health consultations

PT/OT/SW

Facilitate Pulmonary Rehab referral

Liaise with community supports

Community Wellness Teams/Navigator

Smoking Cessation

Community health centers – COPD education sessions twice per year at each of the area sites

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Miscellaneous

Team phone number provided to patients

• One member answers Mon-Fri, 8am-4pm

• Contacts assigned team member to respond

• Allows for support between visits/phone calls/after scheduled interventions complete

Letter to Primary Care Provider after RT/NP visits

• Copy on hospital electronic record

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Follow-up Calls

Usually, after phone call no. 3, no further

planned visits

Remind patients that they can call us anytime

with COPD related issues

We will follow-up again if they are admitted

or frequent ED visits

Mention call at 12 months

Letter to Primary Care Provider - reminder of

PD and Action Plan

No formal discharge from the program* 25

Advance Care Planning

A process whereby a person, often in

consultation with his/her family and

attending health care providers,

thinks about and makes decisions

about her/his future personal care

Main ACP process steps:

Reflection

Discussion with loved ones

Consultation with healthcare providers

Decisions

Communication verbally or written

*Best to engage in process when well and have time

Personal Directive

A legal document in which a capable

person sets out what, how and/or by

whom personal care decisions are to be

made in the event that she/he is no

longer capable of making these decisions

on his/her own

Completion rates for INSPIRED patients

are typically in the 70-80% range,

compared to roughly 13% for the general

public

Role of the INSPIRED

Nurse Practitioner

New to Central zone team – Jan 2018

Provides direct patient care within the home

Most medically complex, unmanaged, truly homebound,

palliative patients, “orphaned” patients

Stabilization

Medication optimization

Dyspnea management

Immunizations in the home

Action Plans

Resource allocation

Role of the Nurse Practitioner

continued…

Primary Health Care in the home

For patients who do not have a primary care provider or

for whom it is very difficult to get out for medical apts.

Chronic disease management, screening, labs, medication

management

No limit to number of visits/phone calls from NP

Provides communication to primary care provider/other

involved practitioners.

Role of the Nurse Practitioner

Statistics Jan – Nov 2018

Involved in care of 204 pts

135 home visits

35% do not have a primary care provider.

Majority of these patients have difficulty accessing primary care

Avoided visits to the Emergency department and subsequent hospital admissions - difficult to capture in terms of statistics

Past 11 months an average of 2 patients per week have received home visits due to concerns of “acute symptoms and changes” – assessment, diagnosis and treatment was provided in the home for these individuals.

Even if only 50% of these visits lead to avoidance of an Emergency Department visit – this would equate to an estimated 52 visits avoided on an annual basis.

2017 Update

cfhi-fcass.ca | @cfhi_fcass.ca

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2017 CTS Update CANADIAN JOURNAL OF RESPIRATORY, CRITICAL CARE, AND SLEEP MEDICINE 2017, VOL. 1, NO. 4, 222-241

Overview of COPD Pharmacotherapy

SABA SAMA

(SAAC)

SABA+

SAMA

LAMA

(LAAC)

LABA LABA+

LAMA

ICS+

LABA

ICS +

LABA

+ LAMA

Ventolin Atrovent Combivent Spiriva Serevent Inspiolto Advair Trelegy

Bricanyl Seebri Onbrez Ultibro Symbicort

Airomir Tudorza Oxeze Duaklir Breo

Incruse Anoro

The Dyspneic Brain

• The anterior insular cortex

– limbic-related cortex

– body representation and subjective emotional experience

• Amygdala

– Midbrain limbic structure

– The hub of fear– Emotional elements of

pain perception

Text

Neural respiratory drive

Capacity overwhelmed

Respiratory Muscles

Increased Load

Motor and sensory cortex

Brain stem

Dyspnea

Air flow obstructionEffusions

MassMuscle weakness

Rib #Obesity

CTS-managing refractory dyspnea in COPD

Marciniuk DD et al. Can Respir J 2011

Opioids for the treatment of breathlessness

Clinically, low-dose regular extended release (ER) morphine

reduces the intensity of chronic breathlessness without

compromising gas exchange in people with moderate to severe

COPD

« There is reasonable supportive evidence of benefit for individualized,

carefully titrated opioid therapy, in closely monitored patients with COPD

and troublesome refractory breathlessness, after optimization of more

traditional pharmacologic and non-pharmacologic therapies »

Vozoris and O’Donnell. Exp Rev Respir Med 2016

The New "Opioid Crisis": Scientific Bias, Media Attention, and Potential Harms for Patients with Refractory Dyspnea. Rocker G, Bourbeau J, Downar J. J Palliat Med 2018;21(2)120-22

Verberkt CA, et al Eur Respir J 2017 (63 articles, describing 67 studies. Meta-analysis)

Summary - Refractory Dyspnea

Management with Opioids

Good evidence to support

Patient testimonial/response provide quality

feedback

Improved quality of life and positive response from

family members

Start low and go slow

Bowel routine is essential

KEEP THE PATIENT/FAMILY AT THE CENTER OF CARE

Lessons Learned

Good to have flexible program to meet patient

needs

BUT, this can be a pitfall as it can be difficult to

recognize when you have nothing further to offer-

efficient/effective use of resources

Important to debrief with team members

Complex cases, information sharing, self-care

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Lessons Learned

Home setting offers greater insight into

actual daily living and ability to manage

Ability to provide caregiver support is key

Enhancing patient and caregiver

confidence

Patients appreciate follow-up and concern

Relationship building with other services,

hospital units, Primary Care, Community

etc.

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Lessons Learned

Patient’s agenda vs. practitioner’s agenda - lots to cover, keep notes at hand but follow patient

Getting in the door, but not pushing – don’t screen people out

Good attitudes – right team members is about more than paper credentials

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Nova Scotia

INSPIRED Spread Collaborative Teams from Halifax/Dartmouth/Cobequid,

Hants, the Eastern Shore, Cape Breton &

Cumberland

Pre-INSPIRED

N=178

Post-INSPIREDN=178

6 /12 6/12 6 /12(n, % reduction)

CostAversion

ER visits 365 154 -211 (58%)

Admissions 210 79 -131 (62%)

Bed Days 2044 813 -1231 (60%) $1,230,000@$1000/day

ER, admission data, length of stay6 month pre/post data (June 2015)

Cost aversion at 6 months ≈ 2-3x annual program costs45

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Economic Implications

(Nova Scotia)

Preventing Saving 2,000 ED visits $2.3 million

1,300 hospitalizations $19 million

11,900 bed days

Net Benefit: $20 million

In 5 years and reaching 170 Nova Scotians annually(of the ~33,000 living with COPD):

$1 invested yields $21 in savings

Patient/Family Brochure

CHT sessions

Patient & Family Guide –

Available for access:

http://www.nshealth.ca/sites/nshealth.ca/fi

les/patientinformation/1892.pdf

Questions and Discussion

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