As one of Saskatoon Health Region’s priorities, the LiveWell™ Chronic Disease Management Program (LiveWell™ Program) is offered to individuals who have a chronic disease such as diabetes, chronic obstructive pulmonary disease (COPD), heart disease, sleep apnea, asthma, arthritis and other chronic conditions, and their families.
The COPD Toolkit© was developed in response to a demand for practical resources related to establishing a chronic disease management program from an increasing number of certified respiratory educators across Canada. The Saskatoon Health Region, the University of Saskatchewan and the Lung Association of Saskatchewan collaborated on this project in order to provide a practical blueprint for health care professionals to adapt and utilize in their own communities. The community that wishes to use The Toolkit© may use it in whole or in part, depending on the needs of the patients in their community and the availability of resources.
In response to Bourbeau’s Reduction of Hospital Utilization in Patients with Chronic Obstructive Pulmonary Disease: A Disease-specific Self-management Intervention study (2003), coupled with the introduction of Wagner’s Chronic Care Model (1998), the Health Region coordinated its services in order to facilitate pulmonary rehabilitation in the Region, thereby meeting its identified goals. The goals of The Toolkit© mirror the Health Region’s goals which are:
- To facilitate the development of COPD programming including exercise, disease-specific management and self-management;
- To enhance existing COPD programs that offer exercise, disease-specific management and self-management.
There are currently three pillars of care within the LiveWell™ Program that have evolved since the introduction of Wagner’s Chronic Care Model in 1998:
- Exercise: includes community-based exercise and rehabilitation programs providing personalized exercise prescription, education sessions and group and social support.
- Disease-specific Management: each person with COPD is assigned a case manager, or COPD nurse clinician, who is linked to a multi-disciplinary team working closely with the patient, the family physician and the specialist to provide optimal evidence-based care, education and support.
- Self-management: includes a peer-led support workshop involving two and one half hour sessions, once a week, for six weeks. Sessions empower people with COPD to manage their health and maintain active, fulfilling lives.
Although the information in The Toolkit© is organized within particular pillars of care, there is much overlap between pillar components. Because of this overlap, the participant will receive introductory information during the initial session, with reinforcement of key messages in later interactions with other team members. For example, if the participant accesses our program through the COPD nurse clinician, the participant will receive information about the plan of action, medications and delivery devices, coping with a chronic condition, healthy eating, breathing techniques, exercise, managing fatigue, oxygen therapy and travel, and end-of-life issues. When this participant enrolls in the exercise component, these topics are then reinforced. Similarly, when attending the self-management sessions of the Living Well™ with Chronic Conditions, the participant will receive additional reinforcement in the areas of symptom management, relaxation techniques, how to get the most out of life, exercise and nutrition. Although there appears to be overlap, providing similar messages in a slightly different environment can facilitate behaviour change.
Discussion of the information in The Toolkit© is organized according to the three pillars of care that form the framework of the LiveWell™ Program. Each pillar discussed will include information in the following areas:
- description of the current service provided
- tools specific to description topics are listed
- process for people with COPD to access the service
- tools specific to process topics are listed
- additional tools available for use. For example:
- sample forms
- plan of action
- equipment required (where applicable)
- education resources that can be used, including where to obtain copies of handouts.
- sample forms
Some of the tools provided in this resource have region-specific logos and contact information on them. They are provided as a sample and are in NO WAY intended for exact duplication. Logos and contact information on the tools must be deleted and replaced with your health care community’s/region’s appropriate logos and contact information.