Caring for My COPD

The ‘Hamilton Niagara Haldimand Brant Caring for My COPD’ program is a new community based program for patients recently hospitalized with an acute exacerbation of their COPD which provides a bundle of services using principles of Chronic Disease Management, including enhanced case management and strengthened self-management.

Please find attached a one paged document about the Caring for My COPD program, the referral form and brochure.  If you have patients with COPD in your program it is important to share the attached documents with your team  as the Caring for My COPD program aims to improve patients quality of life, the management of their condition, and reduce hospital readmissions and ER visits. 

Process for referral to the Caring for My COPD program: Patients are referred from hospital prior to discharge (by the Most Responsible Physician, NP or designate).  This program is for patients recently hospitalized with modifiable COPD and who are able and willing to travel to a community centre for a core program of exercise and education. This program is NOT for patients residing in long-term care facilities, medically unstable patients, and patients with end stage COPD.

Please ask and document in the chart if eligible patients would like to be referred to the Caring for My COPD program. Complete the attached referral form and fax both the referral form and COPD Discharge Bundle to the Grand River Community Health Centre as the program is now open.

Key features of the program include:

  • Tailored intervention to assist the patient and their health care team in increasing medical stability and capacity for managing COPD at home and in the community.
  • A 10 week program followed by monthly telephone calls for one year. Program elements include: education (smoking cessation, medications, and nutrition), exercise, assessments (i.e. spirometry, oximetry), mental health and wellness, peer support, and spiritual care.
  • Case management by a Certified Respiratory Educator (CRE) trained Coordinator in collaboration with the primary care provider and/or respirologist to reduce hospital admissions and ER visits.
 
Designed By  Blueprint Agencies