Integrated care model with self-management in chronic obstructive pulmonary disease: From family physicians to specialists

• Published in: Chronic Respiratory Disease 2013-05, Vol.10 (2), p.99-105
• Main Authors: Bourbeau, Jean, Saad, Nathalie
• Format: Article
• Language: English
• Subjects: Continuity of Patient Care; Delivery of Health Care, Integrated - methods; Family Practice - methods; Humans; Patient Care Team; Primary Health Care - methods; Pulmonary Disease, Chronic Obstructive - therapy; Pulmonary Medicine - methods; Secondary Care - methods; Self Care - methods
• ISSN: 1479-9723; 1479-9731; 1479-9731
• DOI: 10.1177/1479972312473844

Patient with chronic obstructive pulmonary disease (COPD) has to become a partner and an active participant in his own care, that is, disease self-management. The goal of this article is to present successful and unsuccessful interventions using patient self-management and to propose a model of integrated care more suitable to the needs of COPD patients. This is a narrative review and an opinion article. Many systematic reviews have shown positive outcomes for patients with COPD. These studies have in common a self-management intervention including an action plan in the event of an exacerbation embedded in an integrated health-care system coordinated by a case manager for educational sessions and regular communication. Recently published trials have brought controversy with respect to the effectiveness of self-management programmes, especially in patients with high burden of disease and co-morbidities. It may be more challenging to make the patient with high burden of disease a partner and not without risk of serious adverse events. Finally, our health-care delivery has to be well integrated and more coherent, that is, strategic alliance between primary and secondary care, and supported by interdisciplinary teams for patients with high-risk and complex COPD. Clinical practice has to be structured to address COPD throughout the disease spectrum, that is, secondary versus primary, team work, partnership, self-management and continuity of care.