Implementing a Novel and Supportive Program of Individualized care for patients and families Living with Respiratory Disease (INSPIRED)

HOW IT WORKS

INSPIRED provides patients with chronic obstructive pulmonary disease (COPD) with multidisciplinary team-based care in the hospital, during transitions to other care settings, and in the home. This team includes a certified respiratory educator (nurse or respiratory therapist), social worker or spiritual care provider, primary care physician, and pulmonologist. It provides patients and their caregivers with a tailored treatment plan and extensive education, including specific goals of care, action plans for COPD treatment, decision-support tools, and advanced end-of-life care plans. In some regions, INSPIRED targets people hospitalized within the last year; in other regions, it focuses on individuals who smoked a pack of cigarettes a year for 20 years. In most cases, the program targets moderate-to-severe COPD patients with a Medical Research Council dyspnea score of 3–5, with the intervention intensity tailored to disease severity. The program is mostly based in hospitals (where most intake and coordination occurs) or in primary care settings.

IMPACT

The initial model has spread to 19 sites across all 10 Canadian provinces through a collaborative led by the Canadian Foundation for Healthcare Improvement (CFHI). Published evaluations report that the initial program improved patient outcomes and reduced health care costs.

WHAT’S INNOVATIVE

For providers

The program targets COPD patients in all care settings. There is a moderate degree of collaboration and information-sharing across all sites, with certified respiratory therapists serving as key coordinators. Education and counseling comprise a large share of staff time. The care team helps educate other providers on the value and content of action plans.

For patients/caregivers

COPD’s symptoms and exacerbations can be reduced, but the condition is inherently life-limiting. Patients receive extensive education and training in self-management skills to increase autonomy. Comprehensive care of this type, with shared-action plans driven by patients and caregivers, is not typically available for COPD patients. The focus on spiritual counseling, end-of-life care, and palliative approaches throughout patient care is unusual for this population in Canada.

GOVERNANCE

The program can be led by family health teams, hospitals, home care agencies, or regional health authorities. The steering committee includes representatives from all these settings, with each providing staff and funding. Involvement of patients and caregivers in running the program varies across regions, but their engagement is an area of future focus for the model.

SUPPORTIVE POLICIES

COPD is a priority condition, responsible for up to one-quarter of all hospitalizations. The model, developed in Nova Scotia, was spread to 19 sites to encompass every province, through a collaborative led by the Canadian Foundation for Healthcare Improvement (CFHI). This activity was followed by a scale collaborative across six regions, along with a range of smaller initiatives to address COPD across the country. The INSPIRED model is included in some bundled-care programs that incentivize collaboration across the continuum of care. The organization of primary care into multidisciplinary teams in some areas has facilitated spread.