Program overview :

Self-management of Chronic Obstructive Pulmonary Disease

Centre intégré de santé et de services sociaux (CISSS) des Laurentides

CISSS des Laurentides has implemented a virtual care initiative to enhance the self-management of chronic obstructive pulmonary disease (COPD) among patients in the Laurentides. Sub-optimal management and unfamiliarity with the signs and symptoms of COPD can cause more frequent episodes of secondary bronchial infections. Repeated secondary infections can seriously harm a patient’s health and increase their number of visits to the emergency department.
This project helps users and caregivers better monitor the illness by providing them with support and education. This helps nurses and doctors provide speedier care when users need it. It has been proven that access to virtual care makes for speedier treatment, increased access to care, reduced isolation and fewer visits to the emergency department. It also improves self-management of COPD and ensures residents of the Laurentides can have high-quality, local care.

Objective and purpose of the promising practice

Access to the virtual care service platform aims to empower COPD patients and caregivers through personalized learning. This makes it possible for the patient or caregiver to detect the signs and symptoms of an exacerbation early on. This allows for a quicker intervention, improving the patient’s quality of life and cutting down on visits to the emergency department.

Nearly 800 patients receive regular treatment at the Saint-Jerome Hospital COPD Clinic and Saint-Eustache Hospital Respiratory Clinic. Many lack the knowledge and resources to manage their illness effectively, resulting in frequent emergency department visits and occasional hospitalizations. Through this project, an additional four patients were introduced to virtual care each week, with the goal of having 40 percent of clinic patients registered and active on the platform.

Approach

Engagement

Resource patient partners also played an important role with platform implementation and ongoing improvement, particularly in designing questionnaires to detect exacerbating signs and symptoms of COPD. Patients and caregivers continue to be engaged for feedback to make the platform easier to use and understand. The project team also collaborated with respiratory therapists, nurses and clinicians at CISSS des Laurentides, collectively developing indicators to monitor project progress after implementation.

Outcomes

Since the project’s implementation, CISSS Laurentides has observed a reduction in emergency department visits and hospitalizations related to COPD exacerbations. The virtual, at-home care platform has enabled quicker personalized interventions and therefore better control over the disease.

Personnel who participate in the project are able to monitor a large number of patients efficiently and intervene when necessary, leading to fewer calls to outpatient respirology clinics and fewer procedures required by pulmonologists. Overall, patients feel like they are better able to manage their illness and have more continual support.

Following the project’s success, Hôpital de Saint-Jérôme’s neurology department took steps to roll out a similar monitoring platform for patients with Parkinson’s disease.

Impacts and learnings

Key takeaways

Employees who participated in the project discovered that patients using the virtual platform have specific needs that are different than those cared for in outpatient clinics.
The project team’s professionals collaborated with patients on the design, development and continuous improvement of the platform.
This same team of professionals had access to IT resources and phone support to help users if needs cropped up later on.

Facilitators

Creating a step-by-step user guide for the virtual platform.
Ensuring the virtual care platform was beneficial for patients was key to successful implementation.
Providing accessible IT support for patients and caregivers.
Automatically relaunching the platform after periods of inactivity to detect usage problems that the patient might be experiencing.
Providing a health library directly in the platform that could be used as a tool for personalized patient learning.
Leveraging reference resources from other organizations to facilitate rollout of patient support.

Barriers

Some patients found it challenging to understand and use digital information.
Issues with internet connectivity.
Patients uninterested in regular monitoring, despite efforts to engage them.
Some patients found completing daily questionnaires burdensome.

The virtual care initiative at CISSS Laurentides demonstrates a promising practice in enhancing COPD management. By leveraging technology to improve patient self-management, the project has shown significant benefits:

Fewer emergency department visits
Personalized learning tailored to clients
Improved support and safety for patients and caregivers
Better disease self-management
Improved quality of life for patients by reducing isolation, as well as inspiring further innovations in virtual care for chronic conditions

For more information:

Geneviève Labrèche
Regional electro-respiratory care coordinator of nuclear medicine and the vascular laboratory

CISSS des Laurentides
genevieve.labreche.cissslau@ssss.gouv.qc.ca