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COPD Case Management

CMC-NorthEast

February 2012

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Case Study

72 year old

Retired postal worker

Smoked ½ pack a day for 40 years

Now diagnosed COPD

Inpatient 10 days

Discharged with follow-up to Medical

Home and Pulmonologist

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First few weeks – begins to adjust to his

lifestyle changes including:

� Portable O2

� Frequent MD Visits

� Smoking Cessation

� Medication - New

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“He feels out of control”

Case Manager – calls patient within 48

hours – he says he is experiencing no

side effects except the “jitters”. He is

nervous and just needs “a cigarette”.

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CM – reviews the psycho social and

clinical data.

#1 Goal to build a trusting relationship and

credibility with the patient.

#2 To ensure our patients develop the skills and

knowledge to be their own case manager.

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CM Interventions:

Developed a health action plan in collaboration

with the patient.

Health Action Plan: A collaborative short-term plan developed collaboratively with patient and case manager – reviewed with PCP

PRIORITY AIMS HEALTH ACTIONS RESP

Coordination of Medical Care

� Meet with PCP – March 3

rd - 9am

� Meet with CM – March 3rd

- 8:30am � Meet with Pulmonologist � Done O2 – Healthy @ Home � Nicotine patch as ordered � Meet with Pharmacist – March 18

th – 11am

Patient Patient Patient CM Patient Patient

Self-Reliance

� Will log my symptoms of SOB, jittery � Will Call Healthy Living class to get scheduled

Patient Patient

Daily Activity and Fitness

� Will walk to mailbox every day at 2pm for 6 days � Will get scheduled for Pulmonary Rehab – April

Patient Patient

Independence with Family and Friends

� Will visit with the Parish Nurse weekly

Patient

Educate Patients to Disease Process and Prevention

� CM will call weekly to check in � CM reviewed with flip chart – physiology COPD &

symptoms � CM reviewed each medication with patient � CM shared COPD “Gold” booklet & highlighted specific

areas

CM CM CM CM

Community Involvement and Purpose Mental Challenge

� Will join The Healthy Living – Living with Chronic Disease

Support Group on March 8th

at 4pm

Patient

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Collaborative Health Action Plan

� Reviewed basic disease process and symptoms

� Educated on importance of smoking cessation

� Reviewed options with patients and his insurance coverage

for:

� Pharmacotherapy (nicotine, bupropion, etc.)

� Classes, counseling, and support groups

� Individual and group hypnosis

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Reviewed other short and long term goals:

� Preventing disease progression

� Medication adherence

� Improving exercise/tolerance

� Ongoing education to patient/family/caregiver

about lifestyle changes

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Educate

� Manage symptoms (SOB, wheezing, temp,

change in sputum)

� How to prevent and manage

complications/exacerbations

� Developing a list of questions to ask the

PCP and pulmonologist (his “insomnia”,

“fatigue”, & “depression”)

� Educate family on severe changes in

alertness and when to call the MD vs. ECC

� Coach in self-management

� Referral to pulmonary rehab

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The Medical Home CM works with patient/family/caregivers

in assisting him to regain control over his life.

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6 months later:

� Patient reports his health is improving

� With her support, joined a gym and

exercises 2 hours 3 times a week

� Successfully stopped smoking with

patch

� Adhering to his medication regime

� Visits his Medical Home on a regular

basis

� Is now leading the Healthy Support

Group

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