Www.pspbc.ca Shared System of Care (COPD) Learning Session 2 It will take your breath away

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Shared System of Care (COPD)Learning Session 2

It will take your breath away

2

What did you try? Tell us about your challenges Tell us about your successes What surprised you? What will you try next?

Case Finding with COPD 6: Table Discussion

3

41. Parkes G et al. BMJ 2008;336:598

Motivating Patients to Quit Smoking:Their Lung Age is More Important Than FEV 1

% of smokers who quit after receiving test

results

5

Registry Development Smoking Cessation interventions COPD Action plans Specialist Referral

› What did you try?

› Challenges

› Success

› Surprises

› What will you try next?

Other Action Period MeasuresTable Discussion

6

Following COPD In the Office

7

Frequent exacerbations Higher MRC score/Dyspnea Severity of airflow obstruction On home oxygen Multiple co-morbidities Low BMI…

Who is at higher risk and needs more follow-up ?

8

Spectrum of COPDPrevention and Awareness

Well At-risk With COPD diagnosis

No symptoms Symptoms but no diagnosis

MILDstage

MODERATEstage

SEVEREstage

The earliest point at which airflow obstruction may be detected by spirometry

Damage

Unaware of lung health

Aware of lung health

•Raising awareness of early signs and symptoms

•Promote sustained stop smoking services

•Early identification

‘Upper limits of normal’

‘Lower limits of normal’

VERY SEVEREstage

• Make links with other disease areas, e.g. lung cancer, CHD

• Roles and responsibilities of employers

• Environmental factors

Management of stable COPD

1010

Comprehensive Management of COPDComprehensive Management of COPD

11

Classification of Disease Severity in COPD

12

GOALS Symptoms Exacerbations Exercise

Beta - agonistsAnticholinergics Short vs. long-actingInhaled corticosteroidsCombination therapies

AntibioticsOral prednisonePDE4 inhibitorsOxygenPulmonary rehabilitationSmoking cessation

Treatment of stable COPD

1313


GOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

14

Short-acting Bronchodilators

1515



1616


Stepwise increased therapyGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

17

Mild

Increasing Disability and Lung Function Impairment

Infrequent AECOPD

(< 1/year)

Frequent AECOPD

(> 1/year)

LAAC or LABA+ SABA prn

LAAC + LABA + SABA prn

LAAC + ICS/LABA* + SABA prn

LAAC + ICS/LABA +SABA prn

SABA prnpersistent disability

LAAC + SABA prn

or

LABA + SABA prn

persistent disability

LAAC + ICS/LABA +SABA prn +/- Theophylline


Moderate Severe


O’Donnell DE, et al. Can Respir J 2007

* Inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) combination with the lower ICS dose i.e. SALM/FP 50/250 µg twice daily

Optimal Pharmacotherapy in COPD

1818



19

Spirometry essential as screening tool in patients at risk Beware false positive/false negative results Treatment: Mild: Short acting BD’s) Moderate: Long acting BD’s (single or comb) Severe: Combination BD’s + ICS +Pulmonary Rehabilitation

Summary

20

Dyspnea out of proportion to spirometry

Young age of onset

Remote smoking history and disease severity not consistent with

smoking history.

Rapid deterioration (symptoms or FEV1).

History of exacerbations.

Concern re multiple co morbidities

Stable COPD: Who should be referred ?

21

79yo woman severe SOB PHx: Overweight (BMI 32), diet controlled DM2, & HTN Allergy: mild seasonal allergies - rhinorrhea Smoking: 40 pack. years - quit 20 y ago. Spirometry: FEV1 78% pred & normal FEV1/FVC ratio. No post BD

change. Next step?

Case #1

22

1. Explore possibility of heart failure/ischemic heart disease/if acute onset consider PE.

2. Could this patient have asthma?3. Exam patient and rule out heart failure.4. Chest x-ray. 5. Request testing for reversibility and if normal detailed lung function

obtain lung volume + DLCO6. Echocardiogram7. Stress test

Case #1

23

1. Spirometry with post bronchodilator assessment showed a 12% improvement consistent with the diagnosis of asthma.

2. Echocardiogram: Normal3. Stress test: No ischemic changes

COPD case #1

24

Diagnosis: 1)Adult onset asthma with likely added de-conditioning and obesity,2)Initiate low dose inhaled corticosteroids and short acting bronchodilators PRN.3)Advise re immunizations.4)Provide education about inhaler use and refer for education.5)Provide a written action plan

Key learning points:1)Asthma can occur late in life and can occur independently or in association with COPD.2) Important to identify co existence of asthma in COPD as it will effect adjunct therapies such as beta blockers

Case #1

25

68yo man progressive SOB wit a history of a recent exacerbation requirng a vist to the ED and a course of prednisone and antibiotics.

PHx: HTN on metoprolol and ramipril. Allergy: no seasonal or environmental allergies Smoking: 55 pack.years - quit 5 y ago. Spirometry: 3 years ago: FEV1 53% pred, FEV1/FVC ratio. No post

BD improvement Meds: fluticasone 250 BID, salbutamol 2 inhalations Q4H PRN with

increasing use in the last few weeks. Next step?

Case #2

26

1. Clinically this patient has deteriorated with a recent exacerbation.

2. What would you do next?

Case #2

27

1. You repeat the spirometry and the FEV1 is now 45% of predicted.

2. This patient has severe COPD and a history of exacerbation and therefore would qualify for the use of a tiotropium and salmeterol.

3. Any further deterioration or exacerbation and would use a combination inhaler and tiotropium.

Case #2

2828


Stepwise increased therapyGOLD stages (FEV1) I (>80%) II (50-80%) III (30-50%) IV (<30%)

29

Question: What reliever medication would you recommend for this patient?

Key learning point: ipratropium should not be used as a rescue medication and the patient should be prescribed on a PRN basis salbutamol.

COPD Case #2

30

60yo woman progressive SOB PHx: COPD Allergy: Seasonal allergies years ago Smoking: 25 pack.years - quit 10 y ago. Spirometry: 3 years ago: FEV1 54% pred, FEV1/FVC ratio. Meds: salbutamol and ipratropium bromide PRN and now needing

them up to five times daily. Next step?

Case #3

31

1. Repeat spirometry and FEV1 unchanged.

2. Next steps?

Case #3

32

Add tiotropium bromide, stop ipratropium bromide and continue salbutamol PRN.

Six weeks later patient reports some improvement but still short of breath and has developed peripheral edema?

What are your concerns now and what would you do?

Case #3

33

Clinically there is evidence of congestive heart failure and you start a diuretic and get an ECHO.

The ECHO shows a reduced EF of 35% predicted.

Key learning point: HF and severe COPD often co exist and treatment strategies

need to take account of this

Case #3

34

Questions

3535

Management of severe COPDManagement of severe COPD


36

Maximize inhaled therapy:› Combined ICS/ long acting beta-agonists› Long acting anti cholinergic.

Additional considerations:› Ensure patient is taking inhalers correctly if unable to use

spacer and deliver medication correctly consider nebulized Rx.

› Refer to pulmonary rehabilitation.› If having frequent exacerbations consider the addition of

azithromycin and/or roflumilast.› Ensure no untreated co morbidities such as CHF and GERD

SEVERE COPD

37

Continuous (Grade A evidence) Resting ABG pO2 < 55 mmHg Resting ABG pO2 55-60 mmHg

› Cor pulmonale

› Hct > 56%

Intermittent (Grade B evidence) Exertion: sO2 <87% for > 1 min Nocturnal sO2 <88% for > 30% night

Long term O2 therapyIndications

38

Continuous Home O2Minimum 20h /day

39

Beneficial in extremes of age Coordination not required Breath-hold not required Higher dose

Nebulizer treatment in severe COPD

40

Chronic oral prednisone therapy in COPD

41

There is no evidence base for the regular use of oral prednisone in COPD.

In one RCT of prednisone for ARCOPD one group who were left on prednisone had increased side effects.

For patients who have frequent AECOPD and continue to exacerbate despise all the measures outlined above then an N-of-1 trial of alternate day OCS can be considered.

Bone density and osteoporosis risk should be regularly reassessed.

Chronic oral prednisone therapy in COPD

42

1. Patients with moderate-severe COPD (FEV1 < 50%) ± chronic bronchitis with frequent ( > 2/year ) exacerbations.

2. Patients should be advised re the risk of GI side effects.

Roflumilast: indication:

43

Apart fro azithromax there is no evidence that chronic antibiotic therapy is effective in COPD.

For exacerbation: rotating antibiotics between classes are recommended

A significant minority of COPD patients have co existing bronchiectasis and in the presence of significant sputum volume and purulence assessment for atypical TB infection and gram negative pathogens such as Pseudomonas should be completed.

Other antibiotics for severe COPD

COPD Exacerbation(A.K.A Lung Attack)

45

Definition (2 out of 3):1. Sustained Dyspnea2. Cough3. Sputum: quantity &/or color fever, CXR, constitutional

Risk factors: Previous exacerbations * GERD Reduced FEV1 Diabetes mellitus. C.V. disease

COPD Exacerbation

46

COPD ExacerbationMajor co$t of COPD

47

Soler-Cataluña J J et al. Thorax 2005;60:925-931

Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.

(1) No COPD Ex(2) COPD Ex ER visits no admission(3) COPD Ex one hospital admission (4) patients with readmissions.

COPD Exacerbation

48

Causes:75% infectious

› Virus

› Bacteria

20% environmental5% Other:

› MI/CHF

› Surgery

› Aspiration.

› Pulmonary embolism (20% in one study!) caution - select patient population

COPD Exacerbations

49

Rodriguez-Roisin R Chest 2000;117:398S-401S

©2000 by American College of Chest Physicians

What is COPD exacerbation ?Day-to-day variability of a patient with COPD.

5050

AECOPD: Prevention StrategiesAECOPD: Prevention Strategies

51

No influenza vaccination: 28% No rehabilitation program: 86% No home O2 (PaO2 < 55mmHg): 28% Failed inhaler maneuvers: 43% Current smoker: 26%

COPD ExacerbationModifiable risk factors (EFRAM study)

52

Adams S G et al. Chest 2000;117:1345-1352

©2000 by American College of Chest Physicians

Relapse rate according to each antibiotic group. p < 0.001 for no antibiotics vs all antibiotics, p < 0.001 for amoxicillin vs all antibiotics, and p = 0.006 for no antibiotics vs amoxicillin.

53

MILD COPD or INFREQUENT Older broad spectrum usually enough:

› Septra

› Doxycyxline

› Cefuroxime

› Clarithromycin

SEVERE COPD or FREQUNET Stronger antibiotics

› Quinolones (levofloxacin or moxifloxacin)

› Cephalospirin (cefixime)

› Combination (Macrolide + cephalosporin)

› Special consideration: pseudomonas, enterobacter, MRSA

COPD ExacerbationsANTIBIOTICS

54

COPD exacerbation is associated with significant inflammation and the majority of patients will require OCS.

Lung Attack – Key Learning Point #1

55

Always consider other co morbidities such as GERD,CHF, thromboembolic disease as factors in the AECOPD

Lung attacks: key learning point #2

56

11 studies (1081 pts.) Treatment failure within 30 days with OCS:OR 0.50

(0.36-0.69). NNTT: 10 pts. LOS: -1.22 days (-2.26—0.18). Improved FEV1 and less dyspnoea. No mortality effect. Adverse event: OR 2.33 (4-9). Hyperglycemia: OR 4.95 (2.47-9.91)

Systemic corticosteroids for acute exacerbations of COPD

Cochrane 2009

Meta-analysis of Efficacy: Systemic Corticosteroids and Risk for Treatment Failure

Contemporary Management of Acute Exacerbations of COPD”, Chest Quon BS et al, 2008 ; Contemporary Management of Acute Exacerbations of COPD”, Chest Quon BS et al, 2008 ;

10100.10.1 0.20.2 0.50.5

Relative Risk (95% Confidence Interval)Relative Risk (95% Confidence Interval)

22 5511

Favors PlaceboFavors PlaceboFavors SteroidFavors Steroid

Pooled summary(RR, 0.54; 95% CI, 0.41-0.71)Pooled summary(RR, 0.54; 95% CI, 0.41-0.71)

Bullard et al, 1996Bullard et al, 1996

Thompson et al, 1996Thompson et al, 1996

Davies et al, 1999Davies et al, 1999

Niewoehner et al, 1999Niewoehner et al, 1999

Maltais et al, 2002Maltais et al, 2002

Aaron et al, 2003Aaron et al, 2003

58

Pulmonary Rehabilitation

59

COPD Exacerbation

CASES

61

60yo woman SOB and cough x 1 week

PHx: 1. Moderate COPD (FEV1 56%) 2. CAD, recent MI

Smoking: 30 pack years - quit 10 y ago.

Meds 1. Salbutamol/ipratropium bromide 2 puffs QID PRN 2. Metoprolol, ASA, simvastatin

Next steps?

COPD Exacerbation - Case # 1

62

Does she have a COPD exacerbation?

› SOB

› Cough

› sputum volume

Option 1: start antibiotics: which? Option 2: Antibiotics + Steroids Option 3: close f/u + action plan

COPD ExacerbationCase # 1

63

Option 2: Antibiotics + Steroids Prednisone 50mg x 7days + Septra x 7 days

Less SOB and reduced sputum volume and purulence. What next?


64

Key learning points:1. Patients may take up to six weeks and longer to return to baseline.2. Patient has had an AECOPD and need to optimize inhaled therapy with

tiotropium plus or minus a LABA.3. If symptoms persist consider that the patient may have a component of

asthma and worsening is related to metorpolol or ASA.4. Note beta blockers are safe in pure COPD and have been associated

with reduced mortality


65

60yo woman: SOB x 4 week s Recent 1 week hospital COPD Ex receiving prednisone, azithromycin, cefuroxime.

PHx: 1. Moderate COPD (FEV1 51%) 2. CAD 3. Diabetes

Meds: 1. Formoterol/budesonide 2 inhalations BID2. ASA, Ramipril, Simastatin 3. Metformin

Next step?


66

Does she have COPD exacerbation?› SOB

› No Cough

› No sputum

Option 1: Investigation?

Option 2: Does her maintenance therapy need to be

adjusted?Option 3: Antibiotics + SteroidsOption 4: Pulmonary rehabilitation referral.


67

Repeat spirometry and the FEV1 is now 40% of predicted. Need to optimize inhaled therapy with the addition of tiotropium. Referral for pulmonary rehabilitation. Consider co morbidities: CHF,GERD,OSA, Osteoporosis. Does this patient need home O2? Not likely with an FEV1 of

40% predicted.


68

78yo man chronic severe SOB + coughFrequent admissions to hospital in the last

six monthsSputum colonized with MRSA

PHx: 1. Clinical diagnosis of severe COPD (FEV1 not available) 2. CHF

Meds: 1. Salmeterol and fluticasone 500 BID, Tiotropium bromide QD, salbutamol 2 inhalations Q4H PRN.

2. ASA, Ramipril

Next step?


69

This patient needs objective assessment of his disease severity.

Spirometry shows an FEV1of 30% of predicted. This patient has had multiple admissions to hospital and no

objective assessment if his severe disease.


70

Additional treatment options for severe COPD with frequent ≥ 2exacerbations annually ?


1. Home oxygen assessment2. Theophylline or roflumilast3. Daily azithromycin4. Pulmonary rehabilitation.5. Rule out co morbidities that might be contributing 6. Refer to specialist

71

83 y woman chronic severe SOB + coughmonthly admission to hospital

PHx: 1. Severe COPD (FEV1 33%) 2. CAD previous MI (EF42%)

Meds: 1. salmeterol./fluticasone 500BID, Tiotropium bromide QD, salbutamol 2 puffs Q4H PRN,

2. ASA, Ramipril, simvastatin, furosemide. lasix

Next step?


72

Obtain sputum C+S:› Although routine sputum culture is not indicated this lady has

severe COPD and frequent hospitalizations. She is therefore at risk of Gram negative infection which should be ruled out as

Review exacerbating factors at home?› Smoking (? Second hand)› Adherence › Inhaler technique

How to differentiate CHF vs. COPD?


73

CHF COPD

Dyspnea Orthopnea Edema Responds to diuretic

Respond to Nebs CXR Pulmonary edema Usually N

Spirometry More likely to be N Abnormal

BNP

Note that with mixed COPD/CHF it maybe

impossible to distinguish primary current problem

COPD Exacerbation: case 4

74

Key learning points: Differentiating the relative contributions of COPD and

CHF to patients symptoms is not easy. Careful clinical history taking and clinical examination as

well as judicious assessments including spirometry, BNP and ECHO will be helpful.

Therapeutic trials and referral for a specialist assessment maybe required.

COPD Exacerbations:Case #4

75

Treatment of COPD is more of an art than science. Severe COPD: Maximize inhaled therapy Ensure patient has received pulmonary rehabilitation. Supplemental treatments: O2, trial of theophylline, roflumilast ,

oral steroids, chronic antibiotics COPD exacerbations: Modifiable risk factors Increase use of rescue medication. Provide a written action plan so patient can initiate antibiotics

and prednisone promptly. Recovery maybe slow. Re assess disease severity and address

co morbidities.

ConclusionSevere COPD and exacerbation

76

Symptomatic COPD despite maximal treatment Subjects with frequent exacerbations. Concern re multiple co morbidities especially cardiac. Frequent pneumonias Dependent on oral corticosteroids.

Who to refer ?

77

Answer to specific questions asked by the GP Diagnosis Treatment recommendations

› Alternate treatment

› Modifications to treatment as the disease progresses Responsibilities: roles, when to re-refer patient Include an “echo” Specific locations/clinics where patient should be sent to receive

further tests or treatment

Consult Topics

78

Consult discussion

Video

78

79

Questions

Exacerbation Plan in Self-Management Context

81

Self-management support-a brief summary

Focus on exacerbation (action-flare up) plans within a self-management context

Implementing an exacerbation plan-Table discussion

Objectives

82

Self-management relates to the tasks that an individual must undertake to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management, role management, and emotional management.

Adams, Greiner, and Corrigan (2004)

What is Self-Management?

83

Self-management support is defined as the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment or progress and problems, goal setting, and problem-solving support.

Adams et. Al. (2004)

What is Self-Management Support?

84

Self-Management Education: Reduces Hospitalization

85

Benefits of COPD Self Management Education

86

The Interaction Sequence

Courtesy of Wm. Miller

87

1. Identify the problem.2. List all possible solutions.3. Pick one.4. Try it for 2 weeks.5. If it doesn't’t work, try another.6. If that doesn't’t work, find a resource for ideas.7. If that doesn't’t work, accept that the problem may not be

solvable now.

Problem solving

Source: Lorig et al, 2001

88

When?

› They ask for information

› You ask permission to give it How?

› Ask what they already know

› Fill in any gaps or gently correct misunderstandings

› Concentrate on key messages

› Use Teach-Back

Tips for Giving Information

courtesy of Bill Miller, 2010

89

When?

› They ask for information

› You ask permission to give it

› You qualify your advice to emphasize autonomy How?

› Offer several suggestions instead of one

› End with a question about something they have thought of on their own

› Emphasize it’s their choice

Tips for Giving Advice

courtesy of Bill Miller, 2010

90

Patient’s life context and stage-Broad

Professional perspective-more focused and point in time - e.g. Exacerbation plan

Professional practice approach relates to ‘tasks’ for medical management

How to bring the perspectives together for a patient “action plan”-general and specific-confidence >7/10

Work over time, know your patient

Health professionals recommendations-context

91

Exacerbation Plan (COPD Flare up Action Plan)

92

Understand and accept that they have exacerbations (or even COPD) that need to be and can be prevented/managed

Contract between patient and provider

Monitoring triggers-personal health, environmental

Recognizing symptoms

Taking specific actions-many

Exacerbation Plan – What are we asking of the patients?

93

Given all the things patients have to deal with, how do you support patients to see the importance of working with an exacerbation plan?

How do you increase the confidence level of patients that they can follow the plan?

How do you do follow-up and what do you do?

How do the various providers work together on this with the patient?

Exacerbation Plans in Self-Mgt Context – Table discussions OR ROLE PLAY

Advance Care Planning

95

A process, over time, (can be supported by a patient-focused tool – “My Voice:

• Assist the patient/family in planning

• Informed decisions throughout trajectory.

• Develop an Advance Care Plan (ACP).

• Communicates plan

• May include a formal Advance Directive (AD).

Advance care planning – healthcare

96

Effective September 1, 2011 changes to consent legislation give Advance Directives (AD) legal status.

Legally binding on all healthcare providers (including EMT) MUST be used by TSDM to guide decisions when patient is incapable of deciding

for self. Only Personal Guardian can override. An AD provides written consent or refusal to health care by the adult to a health

care provider, in advance of a decision being required about that health care. AD must be written, signed by a capable adult and witnessed by two witnesses or

one witness who is a lawyer or notary public in good standing with the Society of Notaries Public. A witness cannot be a person who provides personal care, health care or financial services to the adult for compensation, nor the spouse, child, parent, employee or agent of such a person.

Not to be witnessed by physicians BUT discussion of AD should be part of Advance Care Planning prior to patient undertaking AD process.

Advance Directive (AD)

97

1. Capable adult (19 yrs).

2. Personal Guardian (Committee of the person) - court ordered.

3. Representative named in Representation Agreement.

4. Temporary Substitute Decision Maker* (TSDM).

a) Spouse (common law, including same sex)

b) Adult children (equally ranked)

c) Parent (equally ranked)

d) Brother or sister (equally ranked)

e) Grandparent (equally ranked)

f) Adult Grandchild (equally ranked)

g) Another relative by birth or adoption

h) Close friend of the adult

i) Person immediately related to the adult by marriage

j) If no available TSDM, the Public Guardian and Trustee may authorize someone as the TSDM

Who makes your healthcare decisions?

98

Initiate when discussing patient history - patient values and wishes

Routine follow-up appointments for all adults: “I talk with all my patients about this and we talked a little about this last year…”

As part of chronic disease management when discussing care plan: "This particular illness can have a fairly predictable course…here are some things you need to think about ahead of time…"

Following emergency department/hospital admissions: “I understand you have been in the hospital. What did the doctors say?”

Document, document, document ….

When to hold ACP conversations

99

An Advance Care Plan ensures that the patient's wishes are respected when the patient is no longer capable of deciding.

http://www.health.gov.bc.ca/library/publications/year/2012/MyVoice-AdvanceCarePlanningGuide.pdf

Patient wishes

http://www.fraserhealth.ca/media/MyVoiceWorkbookENG.pdf

http://www.fraserhealth.ca/media/MyVoiceWorkbookENG.pdf

Action Planning

101

To create a shared system of care that improves the quality of care and experience for patients at risk for and living with COPD by:

› Identifying early

› Using a team-based approach

› Improving communication

› Improving management

Aim

102

At the GP practice:

Enhanced identification and diagnosis of COPD

Appropriate risk stratification based on level of airflow obstruction and symptoms and exacerbation history – followed by review of prescriptions

Appropriate use of evidence-informed treatments for COPD based on GPAC guidelines

How will we achieve this aim?

103

In a shared care environment:

Implementing more standardized referral and consult letters, and improving relationships, hand offs and communication between GPs and specialist physicians

Developing relationships and care plans amongst GPs, patients, and community services


104

Across the continuum

Supporting patients to quit smoking

Enhancing patient self-management skills for patients to manage their condition

Improving the patient experience with the system of care


105

% of COPD on register having confirmed diagnostic spirometry

% of COPD patients with an exacerbation plan

% of smokers on with COPD offered smoking cessation support

% patients with COPD who have been referred to pulmonary programs where available

% of patients with COPD with a coordinated care plan amongst GPs, specialists, and/or community resources

How will we know if we are implementing changes that will support our goal?

106

% of registry patients reporting an Emergency Department visit or having an unplanned GP visit for COPD since their last appointment.

% of registry patients reporting a hospital admission for COPD since their last appointment

How will we know if we are reaching our goal?

107

Action Period 2

› Continue to screen with COPD 6 Have you tried using other team members?

› Continue to test processes around smoking cessation Have you tried using lung age?

› Continue to populate COPD registry

› Continue to develop and refine GP-Specialist interface

Build on your success, learn from your bumps

108

Action Period 2

› Try using/reviewing exacerbation plans with your patients

› Refer patients to Pulmonary Rehab if available What else can be done if it is not available?

› Link with Home and Community Care where appropriate

Try something new

109

Required for AP1 and 2 funding: 10 Screenings using COPD 6 5 smoking cessation interventions 5 COPD exacerbation plans Develop a COPD registry Discuss consult processes with internist and/or respirologists

Action Period Checklist –

110

Please fill this form out and return via fax to your local coordinator

AP - COPD Data Collection sheet

111

Create your plan with your MOA or other team members

What is one new thing you can you try in your office tomorrow?

What's one new thing you heard here today that you can try in the next week?

Your opportunity to try something new

112

Please fill out our Session Evaluation form Fax your Sessional Invoice directly to BCMA Do not hesitate to contact the PSP team should you

require module support

Thank you for participating in this module.

Evaluations and invoices

113

Appendix

www.pspbc.ca

Storyboard Template

115

Our team aim statement:

Our team members (photo encouraged)

Our team aim statement:

Our Team

116

Insert numeric data, include run charts on key measures for the module.

Our Results so far

117

Changes Tested or Implemented

118

Other changes we couldn’t resist testing

119

From all this testing, we have learned

120

We are surprised by

121

Next, we wonder if we should

122

What is one idea that you want to try? What is one thing you still have questions about?

Reflections

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Tel: 604 736-5551www.pspbc.ca

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Www.pspbc.ca Shared System of Care (COPD) Learning Session 2 It will take your breath away