copd case management cmc-northeast - ihi home...
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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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