Living Well with COPD (Title) - GOLD - the Global initiative for 慢性阻塞性肺疾病以及生活（标题）-金-全球倡议.ppt

Implementation of COPD management programs in Québec, Canada  Jean Bourbeau, MD Associate Professor McGill University Montréal, CANADA The beginning… 1997:  Description of the situation COPD management Mounting evidence indicates that standard care often fails to meet needs of patients with chronic disease Self-management education has proved to be effective in chronic disease such as DM, CHF No self-management program specific to COPD patient National (Canada) National (Canada) Multicentre randomized clinical trial Design Patients randomized ...….. 12 months F/U……….. Multicentre randomized clinical trial Intervention “SM program” “Living well with COPD?” Standardized education flipchart; patient workbooks Ongoing support by a trained health professional weekly teaching(60 min.) for 2-month period monthly telephone contact, and PRN Multicentre randomized clinical trial:Self-management in COPD Self-management Education May Lead to Cost Savings Qualitative Evaluation of a Self-Management Program ?Living Well With COPD?? offered to Patients and their Caregivers Key success elements of the SM program ?Living Well with COPD? Programs involving multiple chronic care model components vs. SM alone Delivery System Design Practice team has defined roles Partnership: Patient active participation in disease management Physician prescribed overall optimal treatment Case manager is the resource person for the patient Other health professionals as consultants, support Regular follow up and coordination of care by physician and case manager Assess patient’s general condition and needs and define goals Help patient/family integrate in daily life the skills and healthy behaviours learned, evaluate and reinforce Provide an Action Plan and support its use Do proper referrals within hospital and in community Decision Support Evidence-based practice ? LWWCOPD Referrals to: Specialized programs: Pulmonary Rehab