Community Care: A Team Based Approach to Managing Chronic Lung Disease

ABSTRACT

Patients with COPD represent the ideal target population which stands to benefit from the Integrated Care Pathway (ICP) model of care. They are generally older and many suffer comorbid conditions which share common causative links to cigarette smoking. Hence their combined medical and social complexities represent a great challenge for the solo physician, whether in specialty or primary care, to deliver care comprehensively, consistently and efficiently. Effective management of patients with COPD thus requires the co-ordinated efforts of the hospital and the community to integrate care across the care continuum. In the COPD ICP Team approach, the execution of care is based on 5 interdependent tenets (1) Every patient has a primary care physician; (2) Every patient’s care should be delivered as a set, rather than individual components; (3) Every patient has a single health record; (4) Every care process must represent value to the patient; (5) Every patient must be helped to navigate care, and supported to remain in care. Of note is the care is supported by care managers, communication links for tracking response to therapy, IT support, and equipment support.