the “nuts and bolts” of the inspired copd educator role · 2018. 12. 14. · copd: our current...
TRANSCRIPT
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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
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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…
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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)
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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.
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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
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INSPIRED COPD Outreach Program
Overview/Patient Experience
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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
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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
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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.
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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/
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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
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Referral Form
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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2017 Update
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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
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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
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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
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Neural respiratory drive
Capacity overwhelmed
Respiratory Muscles
Increased Load
Motor and sensory cortex
Brain stem
Dyspnea
Air flow obstructionEffusions
MassMuscle weakness
Rib #Obesity
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CTS-managing refractory dyspnea in COPD
Marciniuk DD et al. Can Respir J 2011
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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)
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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
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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
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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
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Patient/Family Brochure
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CHT sessions
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Patient & Family Guide –
Available for access:
http://www.nshealth.ca/sites/nshealth.ca/fi
les/patientinformation/1892.pdf
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Questions and Discussion
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