August 09, 2013

Family and specialist physicians throughout BC now have access to training and resources designed to support the effective coordination of care for patients who are at risk of or living with COPD and heart failure.

Developed under the governance of and with funding support from the Shared Care Committee, the Practice Support Program (PSP) System of Shared Care for COPD/Heart Failure learning module has been in the prototype stage, offered selectively within five BC health authorities, as the module development team of family and specialist physicians has worked to refine elements of training and support to best meet the needs of physicians. Combining two PSP modules that each focused on effective shared care of patients at risk of or living with a single condition (COPD, heart failure), the revised module addresses both the complexities inherent in treatment of patients with this particular co-morbidity and a growing need among physicians and their patients.

“COPD and congestive heart failure are the two most common causes of admission to hospital in Canada,” says respirologist Dr Mark FitzGerald, who along with cardiologist Dr Sean Virani led development of the COPD and heart failure components of the module, respectively.

“In 25% of COPD patients admitted, there is co-existing heart failure,” he says. “Management is complicated by the overlap in the signs and symptoms of both conditions. This module provides a framework for the pragmatic management of patients with either condition or patients who are suffering from both.”

The PSP aims to better support physicians to manage patients in the community and avoid hospital admissions or readmission, where possible. To this end, this shared care-focused module supports specialist-guided, family physician-managed care for patients with complex care needs, enabling physicians to work together and with community service providers (e.g., respiratory therapists) to develop patient care plans.

“Few if any chronic disease management programs are taking this integrated approach to the management of both conditions,” says FitzGerald. “Clinicians’ enthusiastic response to the module reflects the challenges many face when managing patients with multiple co-morbidities.”

The module also supports early identification and diagnosis, appropriate use of evidence-informed treatments based on GPAC guidelines, and improved communication and information-sharing between family and specialist physicians, patients, and community-based service providers. Through processes such as appointment confirmation and the use of standardized referral acknowledgement and consult letters, family and specialist physicians are better able to co-manage care of complex patients.

The module includes a range of clinical tools and resources, including the COPD-6 case-finding spirometer, COPD and heart failure treatment algorithms, referral and consult templates and forms, and patient self-management and education resources (e.g., BC Smoking Cessation Program information).