Sustaining Improved Care:
The Breathe Well Program
Respiratory Liaisons
Accelerate Funding
Purpose
Accelerate the work being done by
community integrated health
services
MOH looks at total healt...
Breathe Well Case Management
Model
Moderate to Severe COPD
with 2 ED visits
AND/OR

One Hospital Admission
related to COPD...
Breathe Well Regions
Meet Ed

∗ Insert Video Here.

5

2/24/2014
Purpose of Breathe Well
∗ Provide enhanced care and community resources to
COPD clients who would otherwise return to acut...
Respiratory Liaison
∗ Aims to preserve a low client to clinician ratio to
enable the continuation of a case management
mod...
Breathe Well Physiotherapists

Mobility/home
exercise for
homebound
BW Clients

Symptom
control,
improved
capacity for
imp...
Acute Care Utilization
Acute utilization data includes all ED visits and acute
admissions regardless of CTAS or CMG codes.
Clinical Measures

Adhere to a CTS recommended inhaler regime

81%

Patient diagnoses confirmed by spirometry

80%

Have C...
Patient & Provider Surveys:
The Liaison Role
∗ “Having the RT as case manager has been very beneficial to my clients.
As a...
Patient Pathway
Together
We are enabling appropriate
care, building capacity &
sustaining the ability to
Breathe Well!
Thank You
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Sustaining Improvement: Interior Health Authority Breathe Well Respiratory Liaison

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This was presented in session B3 at the Quality Forum 2014 by:

Cory Bendall
Regional Practice Lead - Breathe Well
Interior Health

Published in: Health & Medicine
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Sustaining Improvement: Interior Health Authority Breathe Well Respiratory Liaison

  1. 1. Sustaining Improved Care: The Breathe Well Program Respiratory Liaisons
  2. 2. Accelerate Funding Purpose Accelerate the work being done by community integrated health services MOH looks at total health costs : Health Authority, Pharmacy and Physicians Care of People with COPD not just Disease Specific Interventions Summary Evaluation After 3 years Formative Evaluation Every Quarter
  3. 3. Breathe Well Case Management Model Moderate to Severe COPD with 2 ED visits AND/OR One Hospital Admission related to COPD in the last 12 months ∗ level 3: Enhanced services for complex COPD patients most at risk for hospital admission ∗ level 2: Build Capacity ∗ level 1: Triage to Avoid Progression
  4. 4. Breathe Well Regions
  5. 5. Meet Ed ∗ Insert Video Here. 5 2/24/2014
  6. 6. Purpose of Breathe Well ∗ Provide enhanced care and community resources to COPD clients who would otherwise return to acute care for service. ∗ A home based program that provides collaborative case management for moderate to severe COPD clients. ∗ Our goal is to reduce barriers and help change behavior to avoid acute care, or reduce a needed length of stay.
  7. 7. Respiratory Liaison ∗ Aims to preserve a low client to clinician ratio to enable the continuation of a case management model. ∗ Allows respiratory clients to be referred to appropriate respiratory or community services with the addition of a triage therapist. ∗ Allows for a better client experience and a fluid transition between acute and community services.
  8. 8. Breathe Well Physiotherapists Mobility/home exercise for homebound BW Clients Symptom control, improved capacity for improved QOL Build access to Pulmonary Rehab in regional hubs
  9. 9. Acute Care Utilization Acute utilization data includes all ED visits and acute admissions regardless of CTAS or CMG codes.
  10. 10. Clinical Measures Adhere to a CTS recommended inhaler regime 81% Patient diagnoses confirmed by spirometry 80% Have COPD Action Plan in place 68% Have medications attached to their COPD Action Plan Have stopped smoking since being admitted to the program 63% 12%
  11. 11. Patient & Provider Surveys: The Liaison Role ∗ “Having the RT as case manager has been very beneficial to my clients. As a team, we have been able to prevent clients from going to ER or being admitted to hospital.” ∗ “This program was a god send to us so that we could navigate the hospital and come home with more support.” ∗ “We are the glue that holds Respiratory services together – all services coordinated : Acute, Home Oxygen, Breathe Well, Community RT, Diagnostics and Rehabilitation.” ∗ Breathe Well is responsive to patients in a holistic manner and walks clients through the process in a very focused way to increase their success to have optimal health outcomes and life they deserve.”
  12. 12. Patient Pathway
  13. 13. Together We are enabling appropriate care, building capacity & sustaining the ability to Breathe Well! Thank You

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