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Integrated Clinical Pathway for COPD

The Integrated Clinical Pathway (ICP) for Chronic Obstructive Pulmonary Disease (COPD) aims to provide comprehensive, coordinated care across healthcare sectors by connecting acute, community and primary care. The pathway focuses on client empowerment, self-management, knowledge translation and collaborative service delivery to help improve disease outcomes and positively influence quality of life.

Image by CNordic Nordic
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The OHT-Northumberland Integrated Clinical Pathway for COPD focuses on specific Health Quality Ontario (HQO) statements to guide the work to ensure Best Practice and resources related to COPD management with resources identified in the local and virtual context. For more information about HQO quality statements, please refer to COPD Quality Standard Implementation Toolkit

The types of services available for diagnosing, treating and supporting clients with COPD may include: 

  • Diagnostic spirometry testing

  • Pulmonary Rehabilitation programs

  • Home Oxygen therapy

  • Comprehensive COPD self-management education

  • Respirology specialist referrals

  • Palliative care supports

  • Smoking cessation programs

COPD Confirmation

Q1: Diagnosis confirmed with spirometry

Northumberland Hills Hospital 

https://nhh.ca/patient-care-services/laboratory-services  

https://nhh.ca/document/pft-requisition  

Campbellford Memorial Hospital  

Referral by fax at this time  

LVFHT – Lung Health Program (for rostered patients)

Best practice guidelines

Q2: Comprehensive assessment 

E2Ps EMR-Integrated COPD Tool 

COPD Patient Care Flow Sheet (Follow-Up Visit) 

Family Physician Airways Group of Canada's COPD assessment template for clinician for follow-up visits. 

COPD Patient Care Flow Sheet (Initial Visit) 

Family Physician Airways Group of Canada's COPD assessment template for clinicians for initial assessment and diagnosis. 

COPD Diagnosis and Management Algorithm 

Lung Health Foundation's step-by-step algorithm for COPD diagnosis and management. 

COPD Assessment Test (CAT) 

The COPD Assessment Test (CAT) is a questionnaire for people with COPD. It is designed to measure the impact of COPD on a person's life, and how this changes over time. 

Q3: Goals of care & individualized care planning 

COPD Action Plan 

The COPD Action Plan is a written contract between patients and their health care team. It will tell you how to manage your COPD flare-ups and will help patients to quickly recognize and act to treat flare-ups. 

CTS template: CTS Template  

Canadian Lung Association template: Canadian Lung Association template  

Living Well with COPD template: Living Well with COPD Template  

COPD Digital Resource Toolkit for Health Professionals 

Toolkit of COPD digital resources to help patients and their families and caregivers learn more about COPD, including risk factors, signs and symptoms, treatment options, and more. 

E2Ps EMR-Integrated COPD Tool  

E2P’s EMR-integrated COPD tool for TELUS PS Suite or Accuro QHR supports primary care by giving them easier access to information they need at the point of care. 

Advanced Care Planning 

Advance Care Planning Ontario or Advance Care Planning Canada 

Dying with dignity    

Q4: Education & self management 

  • Northumberland Family Health Team – COPD Program (Cobourg) 

  • Group sessions on topics like medications, exercise, infection prevention, and nutrition. (open to all Northumberland residents) 
    Contact: 289-252-2139 | https://nfht.ca/copd/  

  • My Lung Health Coach - Lung Health Foundation (Virtual) 

  • Free one-on-one coaching with a Certified Respiratory Educator – 6 sessions over 12 weeks. 

  • My Lung Health Coach is an evidence-based, person-centred COPD self-management and education service delivered virtually by our Lung Health Coaches, who are Certified Respiratory Educators (CREs). It links community members to their very own CRE, who will provide support, information, and coaching so that they can better manage their COPD. 

  • A free, six-month health coaching and remote monitoring program for your patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure.  

  • Lung Health Foundation's informational webpage for patients with COPD, with in-depth descriptions on many topics including symptoms, causes, attacks, treatment, FAQs and resources. 

  • Lung Health Foundation's informational booklet for people living with COPD. 

  • Instructional videos demonstrating inhaler technique by the Lung Health Foundation. 

Q5: Promoting smoking cessation 

  • Patient resources: 

  • Quash app by Lung Health Foundation - a judgement-free app to help you quit smoking or vaping —the way you want! www.quashapp.com  

no smoking.png

Symptom management

Q6: Pharma management of stable COPD 

  • A tool designed to support family physicians and primary care nurse practitioners in identifying and managing COPD in adult patients. Includes up-to-date resources on pharmacological management of COPD. 

Q7: Vaccinations 

  • Lung Health Foundation's webpage on general information about the importance of immunizations, and overview of each vaccine that COPD patients should consider getting. 

Q8: Specialized respiratory care  

  • Lung Health Foundation's algorithm for primary care providers to navigate COPD diagnosis and management. 

  • Consider OTN for specialist appointments when barriers such as transportation and mobility exist for COPD patients.   

Q9/12: Pulmonary rehab  

  • Northumberland Family Health Team – Pulmonary Rehabilitation Program (Cobourg) – available to rostered Northumberland Family Health Team patients via referral. 

  • Virtual Option: 

  • Living Well with COPD: Canadian Pulmonary Rehabilitation Program 

Q13: Palliative care 

  • A curated list of useful resources, articles and website for patients by the Canadian Hospice Palliative Care Association. 

  • An online advance care planning workbook, created by Advance Care Planning Ontario. 

  • Health Quality Ontario's guide to addressing variations and gaps in care in Ontario that need attention when it comes to palliative care. 

  • Community Care Northumberland: Community based and residence (Ed’s House) palliative care services  

Q14: Long term oxygen therapy 

  • Ministry of Health's home oxygen therapy info on their Assistive Devices Program with home oxygen vendor list by geographical location. 

  • The Canadian Lung Association's fact sheet that talks about home oxygen, prescribed as a medicine for some people with COPD. 

  • Local oxygen vendors; 

Exacerbation prevention/management

Q10: Management of acute exacerbation 

  • Lung Health Foundation's informational webpage for patients with COPD, with in-depth descriptions on many topics including symptoms, causes, attacks, treatment, FAQs and resources. 

  • The CTS COPD Action Plan is a written contract between patients and their health care team. It will tell you how to manage your COPD flare-ups and will help patients to quickly recognize and act to treat flare-ups.  

Q11: Follow up after hospitalization for an exacerbation of COPD 

  • A free, six-month health coaching and remote monitoring program for your patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure.  

  • Based on assessment, patient may be appropriate for Remote Care Monitoring program  

Home visits and remote care monitoring 

Community Paramedicine

  • 24-7 access to health services (phone services available 24/7, onsite services available 6 a.m. to midnight) 

  • In-home visits or remote care monitoring of vital signs to prevent escalation of chronic medical conditions 

  • Assessments, referrals, diagnostic procedures, point-of-care testing, vaccinations 

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