The COPD (Chronic Obstructive Pulmonary Disease) Management Program helps patients better manage their COPD, reduce related health problems, and improve their quality of life. The patient is assigned a Registered Nurse case manager who will work with the rest of the home care team in creating the individualized care plan. This team includes Social Workers, Nutritionists, Home Health Aides, Physical Therapists, Speech and Occupational Therapists.
- Education about the COPD disease process including causes, symptoms, and treatment overview.
- Education and support regarding smoking cessation programs.
- Instruction on how to avoid upper respiratory infections.
- Evaluation and education by qualified Physical and Occupational Therapists in home exercise programs individualized to improve patient’s function, strength, and endurance.
- Instruction in energy conservation techniques and exercise management.
- In depth instruction on the medications used to treat COPD.
- Telehealth monitoring of blood pressure, heart rate, pulse oximetry, weight, and temperature; along with disease-related questions which are evaluated by a Registered Nurse.
- Information about flu and pneumonia vaccines.
- Instruction regarding oxygen therapy, nebulizers, pulse oximetry or C-PAP, and bi-level provided by experienced Respiratory Therapists when provided by CHS Home Support Services.
- Individualized plan for self care developed by the patient’s interdisciplinary team of health care providers.
Each patient will go through the COPD Disease Management Program differently based upon his/her disease process and individual needs. Several indicators will be monitored to assess patient outcomes:
- Patient’s ability to verbalize understanding of their disease process, medications, and functional limitations.
- Patient’s compliance with use of oxygen, nebulizers, C-PAP, or Bi-PAP.
- Patient’s demonstration of self care skills.
- Vital signs, including pulse oximetry if ordered by the physician.
- Emotional well being and improved quality of life.