TEAM APPROACH TO COPD DISEASE MANAGEMENT

1. TEAM APPROACH TO COPD DISEASE MANAGEMENT COPD DISEASE MANAGEMENT SYMPOSIUM Friday, January 31st, 2014 LANA BAMIRO, MPH, MBA, RRT, CHES Manager, Respiratory Care Services

2. Course Overview • A multidisciplinary care approach to managing COPD is as important as the patient’s desire to improve their health and wellness • “An effective COPD management plan includes four components: (1) assess and monitor disease; (2) reduce risk factors; (3) manage stable COPD; (4) manage exacerbations”- World Health Organization • With COPD being a multisystem disease, the role of the respiratory therapist, registered nurse, case manager, and pharmacist is as important as the role of the physician • This presentation will review the roles of Respiratory Therapists, Registered Nurses, Case Managers, Pharmacists and Physicians in managing COPD for a patient, and emphasize the importance of patient centered care and teamwork.

3. Objectives • At the conclusion of this presentation, those in attendance will be able to: • Describe the importance of a patient centered multidisciplinary care approach to COPD management • Describe the role of the Patient, Physician, RT, Case Manager, RN, Registered Pharmacist, Registered Dietitian, Occupational Therapist in COPD disease management • Review literature findings for managing COPD from a multidisciplinary approach.

4. COPD Overview • Current research shows that COPD is a fast growing disease with lasting effects on healthcare • COPD stands on similar platforms with Cancer, Diabetes, CHF, and Stroke • “Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading cause of mortality in the world, representing 63% of all deaths.” – World Health Organization • COPD is a comorbid disease with multisystem impacts similar to sepsis • It affects primarily the respiratory tract including the lungs and upper airways, the gastrointestinal system, and eventually the cardiac system • Chronic-OPD implies a disease with long duration and slow progression.

5. Patient Centered Multidisciplinary Care • Treating COPD requires a multidisciplinary approach • Since the disease itself: • (1) involves several organs of the body • (2) cannot be cured but managed • (3) has a comorbid effect on patient care • COPD disease management should mirror similar comorbid diseases such as Diabetes or CHF • Care of patients by a multidisciplinary team is usually organized under the leadership of a physician; each member has specific responsibilities & the whole team contributes to care of the patient.

6. Benefits of A Multidisciplinary Approach “Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” - Andrew Carnegie • Improve patient outcomes • Improve process outcomes • Increase patient satisfaction • Increase staff satisfaction • Reduce malpractice claims • Reduce clinical errors

7. Key Factors Re: Multidisciplinary Approach • Role clarity • Who is responsible for which aspects of care • Who discusses which issues with the patient • Knowledge of one’s own responsibilities as well as that of others • Embrace diversity • Team members must value expertise & contributions that various healthcare professionals bring to patient care • Measure/recognize performance • Solicit feedback from the patient.

8. Members of the COPD Management Team • Patient • Physician • Respiratory Therapist • Case Manager • Registered Nurse • Pharmacist • Registered Dietitian • Occupational Therapist. Red= Primary Care Team Green= Secondary Team

9. The Patient • Seek Help: A patient that would succeed in managing his/her COPD condition will be one willing to seek help • Self-Motivated: This patient must be self-motivated, wanting to take that extra step to improving their conditions • Follow Instructions: A COPD patient that will excel in managing the disease would follow the instructions of the care givers surrounding them • Independent Research: The patient should be eager in doing independent research on what ways he/she could improve their health and wellness and consult the care team regarding findings.

10. Physician… Most likely a Pulmonologist • Diagnosis • A thorough assessment of the patient including history of disease, smoking history, degree of dyspnea, hospitalization history, coping skills, current ADL’s, depression, nutritional status, comorbidities, vaccinations • Goals and Action Plan; this role should be shared with the respiratory therapist since the RT would be the primary project manager of the action plan including education, therapy administration, and evaluation of progress. This should be an individualized program as much as possible, tailored to the patient’s needs post assessment (A pulmonary rehabilitation program is just one part of the action plan) • Evaluation: A frequent assessment of the patient’s condition would allow for modifications of the action plan if needed. Initially, patient visits will be more than normal, but with an improvement in patient condition, evaluation sessions will diminish.

11. Registered Respiratory Therapist (RRT/RCP) • Respiratory Assessment: The RT should perform an assessment on a new COPD patient as well as on existing patients with every visit • Patient Education: The education of the patient on managing their disease with the action plan developed in conjunction with the physician is an important role of the RT. This includes identifying symptoms, smoking cessation, breathing exercises and medication administration in the right way • Progress Notes/Documentation: The role of the RT includes documenting the progress of the COPD patient through the disease management. A patient undergoing a pulmonary rehabilitation program will have a chart for their sessions where the RT will document all activities pertaining to the rehab process • Tests: The respiratory therapist would also be involved in diagnosis of a new patient as well as the evaluation of the patient’s progress through testing. A Pulmonary Function Test is needed to identify the patient’s FEV1 and FEV1/FVC ratio. In patients who are unable to undergo the PFT, the RT could utilize a peak flow meter for a quick assessment of the patient’s peak inspiratory flow.

12. Case Manager • Coordination: The role of the case manager in managing the COPD patient involves coordinating the care needed for the patient who likely has other comorbid diseases such as Diabetes and CHF • Resource Allocation: The case manager would help identify resources, locally, that the patient could use in improving their health and wellness as they journey through the pulmonary rehabilitation program or other disease programs • Support Team: The case manager would also provide support for the patient through recommendations on what support groups may exist to aid their disease management process.

13. Registered Nurse (RN) • The RN’s role is more inclusive for an inpatient setting • The patient’s nurse would provide immediate care needed to the patient by identify when a patient is in distress and making the critical calls needed to alert the Respiratory Therapist or Physician to report to the bedside • The RN would need to understand the different levels of severity and identify what instant remedies such as pursed lip breathing and increased oxygenation could temporarily improve the patient’s conditions.

14. Pharmacist • The Pharmacist’s role is the most important of all secondary team members • The Registered Pharmacist assists the patient identify what combination of drugs work best • They counsel the COPD patient to take the appropriate dose of rescue medications • They also help patients identify when to activate the next medical level of their action plan.

15. Registered Dietitian • The role of the Dietitian is to assist patients who are finding it difficult to prepare balanced diet identify what food items could be made without diminishing the patient’s resting energy expenditure • The dietitian assists the patient with their nutritional needs in order to avoid malnutrition, weight loss and diminished energy levels • The RD identifies what diet is best with the patient’s energy levels.

16. Occupational Therapist • The OT’s role is to assist with the activities of daily living and ensure those activities are not interrupted by the patient’s illness • They stand as consultants to the M.D & RCP who are developing & implementing the action plan for the patient • The OT’s expertise is needed for patients with severe COPD symptoms; a periodic session with an Occupational Therapist could teach the patient how to live the best life possible.

17. Literature Review • Current practices in approaching COPD from a team/multidisciplinary approach vary • Some organizations utilize different care givers more than others • We’ll review a few published articles on this topic from different facilities and organizations.

18. 1. Multidisciplinary Care of the Patient with Chronic Obstructive Pulmonary Disease • Authors: Anne Marie Kuzma, Yvonne Meli, Catherine Meldrum, Patricia Jellen, Marianne Butler-Lebair, Debra Koczen-Doyle, Peter Rising, Kim Stavrolakes, and Frances Brogan • Author’s Affiliations include: Temple University, Philadelphia, Pennsylvania; Cleveland Clinic, Cleveland, Ohio; University of Michigan, Ann Arbor, Michigan; and Columbia University, New York, New York. • Found in the PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY, 2008

19. Literature Review 1. Abstract • “The National Emphysema Treatment Trial used a multidisciplinary team approach to implement the maximum medical care protocol, including adjustment of medications and outpatient pulmonary rehabilitation for all patients and nutritional and psychological counseling as needed. This article discusses the benefits of such an approach in the care of the patient with chronic obstructive pulmonary disease. Team member roles complement each other and contribute to the goal of providing the highest-quality medical care. The primary focus of the team is to reinforce the medical plan and to provide patient education and support.” • Team included: Nurses, exercise specialists, social workers, dietitians, and physicians.

20. Literature Review 1: Content • The development of the plan of care in this article is broken into Patient Assessment, Goals & Plan of Action, and Evaluation • The patient assessment responsibility is outlined for the physician • The patient assessment included respiratory assessment, history of condition, degree of dyspnea, smoking history, coping skills, depression/anxiety, functional abilities, history of pulmonary rehabilitation programs, learning needs, nutritional status, comorbidities, vaccinations

21. Literature Review 1: Content • The goals and plan of action section focused on individualization for each patient, maximal medical therapy, and patient education • The patient education section focused on symptoms of COPD exacerbation, medication schedule and use of devices, smoking cessation education, Lung volume reduction surgery education, and nutritional strategies • The evaluation section focused on assessing whether the plan is continued or revised based on evaluation of outcomes.

22. Literature Review 1: Conclusion • ”The multidisciplinary model described in this article defines the essential elements of a comprehensive plan.” • Although the team in this article does not include the RCP, PharmD or OT, one could deduce the role of each of the key players as that of the exercise specialist in addition to some of the assessment and evaluator tasks completed by the Physician, and the education of medication and more. • “The team's focus is on providing education and reinforcement the medical plan.”

23. 2. A multidisciplinary approach to the treatment and management of chronic obstructive pulmonary disease • Authors: Stephan F. van Eeden, MD, PhD, FRCP, Jane Burns, MSc, BHSc(PT) • Author’s Affiliations include: University of British Columbia, Vancouver, BC; Pacific Lung Health Centre, St. Paul's Hospital, Vancouver, BC • Found in the BRITISH COLUMBIA MEDICAL JOURNAL

24. Literature Review 2. Abstract • “…The Canadian Thoracic Society recommends a multidisciplinary or team approach to management. Currently, there are significant gaps in managing COPD, which should, like asthma, involve a stepwise approach and include smoking cessation as the pivotal intervention… Pulmonary rehabilitation, education, self-management, and nutritional advice have all been shown to improve quality of life and to reduce exacerbations and hospitalizations in patients with COPD. For optimal management of COPD, a combination of these strategies and a multidisciplinary team approach involving physicians and several allied health care disciplines are essential.”

25. Literature Review 2: Content • This article focuses on smoking cessation, pulmonary rehabilitation, education and self-management, nutritional counseling, bronchodilators, and end-of-life care as the factors needed for an effective disease management program. • It calls on the role of the Physician as the head of the multidisciplinary care team, and scarcely states other health care providers in particular but identifies the need for other care givers to assist the physician through the process

26. Literature Review 2: Conclusion • We can deduce from the sections outlined that the RT will be responsible for the smoking cessation, pulmonary rehabilitation, and bronchodilator therapy sections of the patient’s action plan • The Dietitian would be responsible for the nutritional counseling • The education section could be covered by the Respiratory Therapist or Pharmacist (for medication educations), while the self-management section could be the role of the RN or Case Manager

27. 3. Pulmonary Rehabilitation • Authors: Nicholas S. Hill, MD • Author’s Affiliations include: Chief, Pulmonary, Critical Care and Sleep Division; Professor, Tufts University School of Medicine • Found in the PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY, 2006

28. Literature Review 3. Abstract • “Pulmonary rehabilitation programs use multidisciplinary teams to optimize physical and social functioning of patients with chronic respiratory impairment. These programs provide rehabilitation in inpatient, outpatient, or home settings, using at least three sessions weekly (one may be unsupervised) for at least 6 wk. The programs usually consist of exercise training, education, and psychosocial/behavioral components…”

29. Literature Review 3: Content • This article describe the ideal pulmonary rehabilitation program • The author speaks on the goals of a PR program to “alleviate symptoms, restore functional capabilities as much as possible, and reduce handicap, thus enhancing overall quality of life.” • He writes about the structure of the PR program to include the Pulmonologist, Respiratory Therapist, Physical Therapist, Occupational Therapist, Nutritionist, Social Worker, Psychologist, and Nurses in an inpatient setting.

30. Literature Review 3: Content/Conclusion • The settings discussed includes an outpatient setting, an inpatient setting, and a home setting. • The essential components of a PR program in this article include exercise training, frequency, intensity, specificity, education, and psychosocial & behavioral components. • The author believes in the efficacy of a multidisciplinary approach to COPD management via the pulmonary rehabilitation program citing roles for care givers outlined.

31. References • Community Relations Commission, City of Columbus, Ohio. Quotes on Collaboration, Media Section. Retrieved 1/24/14, online website http://crc.columbus.gov/content.aspx?id=41109 • Fabrizio Luppi, Francesca Franco, Bianca Beghé, Leonardo M. Fabbri. (2008) Treatment of Chronic Obstructive Pulmonary Disease and Its Comorbidities. Proceedings of the American Thoracic Society5:8, 848-856 • Nicholas S. Hill, MD. (2006) Pulmonary Rehabilitation. Proceedings of the American Thoracic Society 3:1, 66-74  • Stephan F. van Eeden, MD, PhD, FRCP, Jane Burns, MSc, BHSc (PT). (2008) A multidisciplinary approach to the treatment and management of chronic obstructive pulmonary disease. British Columbia Medical Journal, 50:3, 143-147 • World Health Organization. COPD Management, Chronic Respiratory Diseases Section. Retrieved 1/27/14, online website http://www.who.int/respiratory/copd/management/en/

32. Summary • There is no I in Team (Cliché, I know), but the phrase stands the test of time • The Patient, MD, RCP, Case Managers & RN may play the primary role in the patient’s care, but as you can tell some of the work crosses multiple scopes of practice • The patient remains the central focus, and so long the team knows this, they can work cohesively • Knowledge on who does what, and where the buck stops regarding certain issues is important for logistics, but fluidity is as equally important because no 2 patients are alike.