When Gordon Ying was admitted to North York General Hospital for a chronic obstructive pulmonary disease (COPD) flare-up, he said it changed his life. Through the hospital, he enrolled in a new program that connects acute care (hospital care), community care and primary care (e.g. family physicians), which taught him the techniques to take control of his condition.
Launched in March 2016, the North York Central Integrated Care Collaborative program for COPD focuses on coordinated care and communication between hospital, community and primary care providers during and after hospital discharge. With this program, patients with COPD will receive a coordinated approach to care that starts at North York General with a Clinical Care Consultant, and continues for up to eight weeks after discharge.
During the eight weeks, the Clinical Care Consultant, family doctor and community partners from Circle of Care, North York ProResp, Saint Elizabeth and West Park Healthcare Centre, work together with the patient and their family to ensure the right interventions are in place. This includes home assessments from a registered nurse within 24 hours, a respiratory therapist within 48 hours and a physiotherapist within the seven days. Patients are then enrolled in either the Outpatient Pulmonary Rehabilitation Program at North York General or home rehabilitation provided through the community partners.
Gordon was the first patient to be enrolled in the program and on May 20, he completed the last Outpatient Pulmonary Rehabilitation class. “Before I started this program, I couldn’t do what I am able to do today,” says Gordon. “My appetite is better, I’m sleeping through the night, I’m able to walk for longer, and I don’t cough as much anymore. This amazing team of people helped me understand COPD, taught me how to manage it, and the exercises through rehab helped me regain my strength to take control of my life again. I have already enrolled myself in another exercise class so I can maintain my health.”
Leigh Guertin is a registered respiratory therapist and the Clinical Care Consultant for the North York Central Integrated Care Collaborative for COPD. She explains that patients with COPD or a chronic disease often needs more care and attention. By ensuring patients receive the right education and supports, at the right time it can make a big difference to their quality of life.
“We see a lot of patients who say they know they have COPD but are unsure about what it is or what to do,” says Leigh. “When patients are diagnosed or in hospital, they are getting a lot of information, usually during a difficult time. This often means understanding the diagnosis and following through on appointments and treatments are less likely. We are trying to reverse that process by delivering education and strategies to manage their COPD over an eight week period, during their recovery.”
Leigh says the collaborative approach between acute, community and primary care is the strength of the program. Through developing the program, these organizations were able to come together and breakdown some of the siloes and barriers between providers at different points of care for COPD. The results are a seamless transition of care for patients as they recover, and for patients like Gordon, to see COPD as being a manageable part of his life rather than defining it, and stay out of hospital.