Best Practices for Managing Care Transitions in Patients with COPD

Andrea Matthews, RN

Our Community

• Hartford County
• Parts of Middlesex and Tolland
• HOCC
• UConn

Major Barriers

• Co-morbidities
• Patient self-management
• Poor technique, managing MDI
• Long-standing behaviors
• Patients call EMS first

Best Practices

• Living with COPD Program
• Staff credentialed

Nursing Best Practices

• Patient self-management
• Patient education
• Telemonitoring/telehealth
• Adult learning theory
• Front loading visits

Therapy Best Practices

• Improve functional abilities
• Breathing techniques
• Swallowing

Social Work Best Practices

• Depression screening
• Socialization
• Community resources
• Family/caregiver support

Lessons Learned

• Benefits of tele-health and daily visits
• Physician follow up appt. w/in 7 days
• Call Home Care first
• Adult Learning
• Motivational Interviewing

How does my Community of Care make a Difference?

End of Life Considerations

• 12 million people in US with COPD
• 3rd in most frequent readmissions
• Where patient is in disease process
• Having an honest conversation
• Explore patient goals

Next Steps

• Educate physicians about home care
• Transitional Care Coordination Program
• Community of Care participation
• Reinforce success stories