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A new patient-centered, team-based approach to COPD management

The Sun Country Health Region has launched a new COPD clinic, as part of an overall provincial initiative to strengthen Saskatchewan's health care system.
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(L-R) The COPD Clinic team includes Dietician Lillian Ly, Pharmacy Intern Scott Malek, Pharmacist Christa Vermeulen, Physical Therapist Kaley Mahaffey and Pharmacy Intern Leah Baird.

The Sun Country Health Region has launched a new COPD clinic, as part of an overall provincial initiative to strengthen Saskatchewan's health care system. The clinic's purpose is to improve efficiency in meeting the needs of patients as well as health care providers and communities.

The Ministry of Health has identified six chronic diseases for all regional health authorities to focus on for improvements. Those are COPD, asthma, diabetes, coronary artery disease leading to heart attack, as well as congestive heart failure.

COPD stands for Chronic Obstructive Pulmonary Disease, which is a long-term lung disease that slowly damages the breathing tubes that carry air in and out of the lungs. COPD is the fourth leading cause of death in Canada, with respiratory diseases overall being responsible for approximately 47% of deaths in the province.

Breathing is often difficult for those suffering with COPD, which is caused by smoking in 80% of cases in Canada. Other causes include second-hand smoke, air pollution from dust or chemicals, as well as having had repeated lung infections as a child. In rare cases, a condition called Alpha-1 antitrypsin deficiency can be a cause of COPD.

The team-based approach is a departure from the traditional methods of providing health care to clients.

Research in Canada has shown that these clinics help to reduce emergency room use and hospitalization of patients and that this team-based care model offers more efficient use of doctors' services.

Patients are also more satisfied with the health care system, as their needs are met in a timely manner. Thanks to the team-based care, those with chronic health issues are able to become more knowledgeable about their conditions, enjoy better health overall and have improved access to specialist services.

The teams can include Nurse Practitioner, pharmacist, physiotherapist and dietician. 'Team-based care' is, no matter what combination of practitioner, two or more health care professionals working together to provide care to a patient.

"Our COPD clinic is a wonderful example of team-based care," said Candace Kopec, Regional Manager of Chronic Disease Management, noting that the health region has many other great examples of how teams are working together to make a difference to its residents.

"Doctors, as part of the team, can focus their time on medical issues," she said, "allowing health care professionals - in this case, a nurse practitioner, physical therapist, pharmacist and dietitian - to provide patient education on healthy living and how to manage their condition more effectively."

Rather than going to see a pharmacist, then making an appointment with a physical therapist and yet another appointment with a dietitian, Kopec describes the clinic as being 'like one-stop shopping', putting patients truly at the centre of their care.

"We know that helping patients manage their condition more effectively can make a significant difference to their health," said Kopec.

People who are involved in team-based care tend to make fewer visits to the doctor and have decreased hospitalizations, as they are better able to manage their condition, improving both their health and quality of life.

"The focus is on the management of COPD, including education, teaching patients to self-manage their condition and setting goals," she said. "Key activities include review of breathing, exercises, medication review and nutrition support. There is also a link to a six-week pulmonary rehab course."

Kopec noted that these are exciting times for strengthening primary health care in the province.

"We now have a framework," said Kopec. "The roadmap that has been outlined for a patient-centred health care system is to ensure that every client has timely access to the care they need, that it serves the needs of the community, in a team-based manner to make better use of our health professionals."

The Rural West Primary Health Team, which covers Radville, Pangman, Ogema, Bengough and Carlyle, already offers COPD clinics.

The all-day clinics are held one day each month in Weyburn as well as in Estevan. Appointments are made through a physician's referral, or patients who have been previously diagnosed with COPD can refer themselves to the clinic. Each appointment lasts up to two and a half hours.