Models of care across the continuum of exacerbations for patients with chronic obstructive pulmonary disease

Abstract

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality, and treatments require a multidisciplinary approach to address patient needs. This review considers different models of care across the continuum of exacerbations (1) chronic care and self-management interventions with the action plan, (2) domiciliary care for severe exacerbation and the impact on readmission prevention and (3) the discharge care bundle for management beyond the acute exacerbation episode. Self-management strategies include written action plans and coaching with patient and family support. Self-management interventions facilitate the delivery of good care, can reduce exacerbations associated with admission, be cost-effective and improve quality of life. Hospitalization as a complication of exacerbation is not always unavoidable. Domiciliary care has been proposed as a solution to replace part, and perhaps even all, of the patient’s in-hospital stay, and to reduce hospital bed days, readmission rates and costs; low-risk patients can be identified using risk stratification tools. A COPD discharge bundle is another potentially important approach that can be considered to improve the management of COPD exacerbations complicated by hospital admission; it comprised treatments that have demonstrated efficacy, such as smoking cessation, personalized pharmacotherapy and non-pharmacotherapy such as pulmonary rehabilitation. COPD bundles may also improve the transition of care from the hospital to the community following exacerbation and may reduce readmission rates. Future models of care should be personalized – providing patient education aiming at behaviour changes, identifying and treating co-morbidities, and including outcomes that measure quality of care rather than focusing only on readmission quantity within 30 days.

Interventions to standardise hospital care at presentation, admission or discharge or to reduce unnecessary admissions or readmissions for patients with acute exacerbation of chronic obstructive pulmonary disease: a scoping review

“…34 This marries well with the advice published in a 2020 review article discussing models of care in COPD; discharge bundles should be well defined, tailored to the support needs of an individual, and should be suitable for the context. 50 Overall, the evidence from this review indicates that implementation of care bundles can help to ensure commonly missed elements of care are no longer missed and may enhance compliance with evidence-based treatments for AECOPD. 29 Involvement of those responsible for enacting the change was found to support implementation with stakeholder meeting engagements, 30 education sessions 30 35 end-user feedback 30 33 and mixed communication methods 29 all contributing to improved implementation.…”

“…35 Bundles were described a useful for standardisation of care, providing clarity around the patient pathway, facilitating effective interdisciplinary communication and identifying postdischarge support needs. 50 A recently published metaanalysis of 37 studies looking at bundle implementation for treatment of various conditions echoes Morton et al's findings of low-quality evidence, though still concluding that the implementation of care bundles may be an effective strategy to improve patient outcomes when compared with usual care. 51 Epstein et al propose several key features of their tool that others might model for success including user-friendly design with prepopulation according to evidence-based guidelines, seamless integration into existing electronic resources and provision of clinical decision support to help clinicians under pressure.…”

“… 34 This marries well with the advice published in a 2020 review article discussing models of care in COPD; discharge bundles should be well defined, tailored to the support needs of an individual, and should be suitable for the context. 50 …”

“… 54 55 Like the care pathways, case management interventions were found to be context-dependent, requiring a tailored approach in any setting 54 and should take account of individual patient needs. 50 Although there are benefits to the utilisation of a designated case coordinator, the resource requirement for this type of intervention may not be feasibly replicated in other healthcare settings.…”

Acute exacerbations of chronic respiratory disease: Progress and opportunities

“…The second expert review by Bourbeau and Echevarria 3 describes recent advances in the area of chronic lung disease self-management and innovations to the models of healthcare used to manage acute respiratory exacerbations. It reviews the roles and costs associated with substituting aspects of inhospital care with alternatives delivered via domiciliary programmes (e.g.…”