Concurrent Sessions

B5 Bridgepoint Family Health Team’s “INSPIRE” COPD Management Program

Theme 5. Coordinating care to create better transitions

Presentation Details

  • Date: 10/17/2016
  • Concurrent Session B
  • Time: 3:30pm – 4:15pm
  • Room: Pier 4
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
  • Target Audience: Clinical providers

Learning Objectives

  1. Identify key components of proactive or planned COPD management utilizing various members of the inter-professional team
  2. Learn how to design and implement a COPD management program within your office setting
  3. Understand how the EMR can be a tool for the identification, management and evaluation of COPD patient care
  4. Demonstrate an approach to care coordination and transition into primary care post COPD related ER visits or hospitalization

Summary/Abstract

The “INSPIRE” program is currently being implemented and therefore data collection is underway. We anticipate the following clinical outcomes:

  • Improved MRC Dyspnea Scale and CAT (COPD assessment test) scores
  • High patient satisfaction with care
  • Increased rates of patients who are up to date with their vaccinations – influenza, pneumococcal
  • 100% of patients receive a personalized COPD action plan and referral to smoking cessation resources
  • Reduction in the number of yearly COPD exacerbations, ER visits or hospitalizations
  • 90% of patients will be seen by team within 2 weeks of ER or hospital discharge related to COPD

Presenters

  • Colleen Youngs, Primary Care Nurse Practitioner, RN EC, Bridgepoint Family Health Team
  • Victoria Siu, Pharmacist, Bridgepoint Family Health Team