Collaborating to Improve Care for Patients with COPD

Managing chronic obstructive pulmonary disease (COPD) on your own can be difficult. Environmental or other factors can quietly affect your COPD, leading to a flare up, and in some cases, a trip to the Emergency Department.

COPD is a breathing disorder, often caused by smoking, in which the airway is blocked and breathing becomes difficult. Symptoms include shortness of breath and increased cough and sputum production. Progressive worsening breathlessness can impact daily activities. While there is no cure for COPD, there are treatments that can delay its progression and improve one’s quality of life.

To improve access to services for people living with COPD, Thunder Bay Regional Health Sciences Centre has joined forces with other agencies in the region to form the COPD Working Group.

The COPD Working Group is a collaboration of stakeholders involved in COPD care. Representation on this working group includes community COPD programs in Thunder Bay and Marathon. The group’s objectives are to improve the care experience for people with COPD, to map and support existing community COPD programs, to reduce health system utilization and to problem solve coordination issues with primary care and COPD community programs.

The group meets monthly and represents:

Thunder Bay Regional Health Sciences Centre Advanced Telehomecare Program:

The Health Sciences Centre’s Advanced Telehomecare Program is a home based program for severe to very severe COPD patients who have frequent flare ups. Patients are provided a computer tablet to monitor symptoms of COPD at home and are followed by a COPD Nurse Practitioner and Registered Respiratory Therapist through phone based care with clinic visits when needed. Phone 807-684-6915 for more information, or visit www.tbrhsc.net.

The North West LHIN:

The North West LHIN is committed to improving the health outcomes and quality of life for people living with COPD and other chronic disease through collaboration with clinicians, stakeholders, clients and their families. This includes advancing an integrated and coordinated model for care delivery across the North West LHIN that is person-centred and incorporates self-management, interprofessional collaboration and fosters innovation through the use of technology to optimize equitable access to high quality, evidence informed services.

St. Joseph’s Care Group Pulmonary Rehabilitation:

Pulmonary Rehab is an evidence-based, multidisciplinary program of care that is individually tailored and designed to offer participants the knowledge and self-management skills needed to enjoy a more healthy, active and rewarding lifestyle. It is a program about living with chronic lung disease for those who are motivated to live better and breathe easier.

City of Thunder Bay – Canada Games Complex:

The Canada Games Complex currently offers a special membership through the Chronic Disease Management Program specifically geared toward community-based self-management and healthy skill development in our clients who are living with COPD. The sessions are aimed to reflect activities completed at the St. Joseph’s Care Group Pulmonary Rehabilitation Sessions from the perspective of type of exercise and equipment. Our goal is to provide a safe, accountable and comfortable environment to continue progress made and improve overall quality of life of our participants while also giving social opportunities to forge friendships and mutual support.

The Northwest CCAC Telehomecare Program:

The NW CCAC Telehomecare program is a self-management program that supports chronic disease patients with COPD and/or Heart Failure through health coaching and remote monitoring of vital signs and health information. Patients are provided with easy to use health monitoring equipment and a computer tablet that is set up in their home. Patients are supported by a team of registered nurses and there is no cost for the program. Patients who meet eligibility criteria have a confirmed diagnosis of COPD or HF. For more information, phone 807-767-6960 or 1-855-272-5350.

Palliative Care Services:

Palliative Care focuses on improving the quality of living, and minimizing suffering associated with advanced disease, including COPD. In Thunder Bay, palliative care is provided by nurses, doctors and care providers involved in a person’s living. Increased supports are available from the Community Care Access Centre (CCAC), while physician consultation can be arranged for complex symptoms with a palliative care clinician in the community. Our team can help to minimize the burden of disease through effective symptom control.

Lakehead University School of Nursing:

Nursing student Kristin Colosimo-Hakanen and Dr. Sylvane Filice are collaborating with the working group in conducting an environmental scan of COPD services in the region. The results of the environmental scan will be used to map out services and educate health care providers and patients about what programs are available.