Patient-centered Care for COPD

man wearing oxygen mask

People with chronic obstructive pulmonary disease (COPD) know “breathing easy” rarely is.

The progressive lung disease, which encompasses asthma, chronic bronchitis and emphysema, causes coughing, wheezing, shortness of breath and chest tightness. If it flares, a person can end up in an emergency room or hospital.

Suppose you had COPD and felt an attack coming on. Wouldn’t it be great to call someone who’s part of your doctor’s office team — someone who knows you, can guide you in handling your symptoms on your own or, if necessary, make sure you get immediate medical help?

That’s one way people with COPD could benefit by being part of a patient-centered medical home, says internal medicine physician Andrea Sikon, MD.

A patient-centered medical home is a team-oriented healthcare delivery system that provides more of a continuum of care, especially important for higher-risk patients.

Patient-centered medical home model

The medical home model uses nurses trained as care coordinators for a variety of chronic conditions, including COPD, diabetes and heart failure.

Care coordinators reach out to these higher-risk patients to monitor their progress. They phone, email, text — whatever’s most convenient for the patient — rather than waiting for them to come to the office.

“We realize that after people leave the office, care can be spotty,” says Dr. Sikon. “This fills in the gaps in a way that’s less segmented and more holistic.”

Caring for COPD patients

If you have COPD, care in a patient-centered medical home includes behavioral therapy conducted by the care coordinators. They’ll help you see what you can do to positively affect your health — and avoid those flares that can land you in the emergency room.

Coordinators teach you how to control your symptoms and regularly test your breath capacity with a simple device called a peak flow meter. They’ll chart your progress to keep you on the right track.

They’ll help you to:

  • Stop smoking
  • Take your medications regularly
  • Lose weight
  • Handle stress better
  • Receive critical vaccinations like flu shots

Education and empowerment

Since elements of COPD are under a patient’s control — such as smoking — Dr. Sikon adds that educating patients about the disease involves different, motivational strategies.

“We’re not judgmental, but we ask questions. We ask,‘What do you understand about your disease?’ ‘How does it affect your life?’ ‘How can you change your life to do the things you like to do?’”

By helping people with diseases like COPD to become more proactive in staying healthy, a patient-centered medical home is a way to “provide the right care for the right patients, at the right time and in the right way,” says Dr. Sikon.

Cleveland Clinic’s Medicine Institute was officially recognized as a patient-centered medical home in 2010. Medical homes exist at the Family Health Centers and on Cleveland Clinic main campus. Different models of team-based care are at three of Cleveland Clinic’s primary care locations: Strongsville, Independence and Cleveland Clinic main campus Internal Medicine Department.

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