The Geisinger Health Plan Care Coordination COPD Program is based on the 1995 American Thoracic Society Statement: Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) – Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease Executive Summary April 1998.
The following is a description of the COPD Program and its elements.
Program goals
The primary goal of the COPD program is the early identification of COPD and optimal medication management for all stages of COPD through the following:
- Incorporation of the COPD clinical guideline into a comprehensive health management approach
- Promotion of tobacco cessation for members identified with COPD who smoke
- Promotion of pulmonary function testing to confirm diagnosis and stage COPD.
- Patient self-involvement in the management of COPD
Interventions
Care Coordination nurses work with health care providers and rely on the following interventions when working with Health Plan members enrolled in the COPD program:
- Comprehensive COPD assessment and risk factor stratification.
- Individualized self-management education: medication management, tobacco cessation, energy conservation, and prompt treatment for exacerbation.
- Collaboration with health care provider to obtain pulmonary function testing, optimal medication management, and tobacco cessation as indicated.
- Health promotion services–influenza and pneumococcal administration as indicated.
- Data analysis to support clinical management–percent of members with pulmonary function testing, tobacco cessation, management with bronchodilators.
Program referral
To refer a Health Plan member to the COPD program, please call (800) 883-6355 or (570) 271-8763 between the hours of 8 a.m. to 4:30 p.m.
References
1. 1995 American Thoracic Society Statement: Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD) – Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease Executive Summary April 1998.
