Program of Integrated Care for Patients With Chronic Obstructive Pulmonary Disease and Multiple Comorbidities (PICCOPD+)
Chronic Obstructive Pulmonary Disease, Multiple Comorbidity
About this trial
This is an interventional prevention trial for Chronic Obstructive Pulmonary Disease focused on measuring COPD, case management
Eligibility Criteria
Inclusion Criteria:
- COPD defined as chronic irreversible airflow limitation with FEV1 < lower limit of normal for age as % predicted and a FEV1/FVC ratio < than lower limit of normal (usually 70%) [5]
Plus ≥ 2 comorbidities commonly associated with COPD as identified in the Canadian Thoracic Society COPD guidelines*
- Cardiovascular disease
- Osteopenia and osteoporosis
- Glaucoma and cataracts
- Cachexia and malnutrition
- Peripheral muscle dysfunction
- Lung cancer
- Metabolic syndrome (diabetes mellitus)
- Depression
- Chronic kidney disease OR Other conditions as primary admitting/presenting diagnosis + COPD as significant comorbidity + ≥ 1 other comorbidity
THAT
- Get admitted to participating hospital; or
- Present to participating hospital ED; or
- Have first referral to Respiratory Centre/Respirology team
AND HAVE
- ≥ 1 ED presentation/hospital admission in previous 12 months
- ≥ 50 years age
Exclusion Criteria:
- No access to primary care physician
- Primary diagnosis of asthma
- Terminal diagnosis (metastatic disease with a life expectancy of ≤ 6 months)
- Dementia and absence of family caregiver able to assist with activation of the action plan and feedback on ongoing status and care coordination
- Uncontrolled psychiatric illness
- Inability to understand, read, and write English
- No access to a phone
- Inability to attend follow up at one of the participating sites
Sites / Locations
- Southlake Regional Heath Centre
- Toronto East General Hospital
Arms of the Study
Arm 1
Arm 2
Experimental
Active Comparator
Case Management
Usual care
In addition to usual care, the intervention group will receive case management that includes: 40 minute standardized education session, an individualized action plan, an individualized care plan for management of COPD and comorbidities, standardized reinforcement/motivational interviewing and action plan teach-back sessions and assessment of symptoms, progress and problems, and problem solving by phone weekly for 12 weeks, then monthly for 9 months (21 sessions), tele-home monitoring, coordinated and improved communication between the patient, family caregivers, family physicians, specialists, and CCAC facilitated by the case manager, priority access to ambulatory clinics.
Usual care for these patients comprises: Dictated patient summary, referral to an 8 week in-hospital rehabilitation and self-management education program, referral to a smoking cessation program (as applicable), individualized action plan developed with treating respirologist at the discretion of the attending respirologist, Referral to web based educational materials and resources.