Breathing—you do it all day, every day. When you’re healthy, breathing comes easily. But if you have chronic obstructive pulmonary disease (COPD), breathing is difficult. You need expert pulmonary care to keep it under control. That’s where COPD Transitional Care Teams come in.
The team’s main goal is to help in the transition from hospital to home so you don’t have to return to the hospital.
Why the COPD Transitional Care Team Exists
The NIH reports that approximately 233,000 Maryland residents live with COPD. Smoking is the leading cause of the disease, and chronic bronchitis and emphysema are the most common types.
Symptoms of COPD include:
- Breathing-related issues, such as feeling short of breath (especially during activity), wheezing or having a hard time catching your breath
- Cough that may include mucus
- Feeling fatigued
- Frequent bouts of bronchitis, pneumonia, cold or other respiratory illnesses
Every year, COPD flare-ups lead to more than 700,000 hospitalizations, according to a study in Respiratory Care. Of these patients, approximately 20% wind up back in the hospital within 30 days. The COPD Transitional Care Team is changing that.
Meeting the Team
If you have COPD and are hospitalized at a University of Maryland Medical System hospital, you are placed on a COPD care path. This care path ensures a pulmonologist visits you and gets you a meeting with the COPD Transitional Care Team.
For every appointment, the whole team comes together to ensure they’re all on the same page as they develop a care plan for you in real time. It also empowers you to participate in your care as they discuss your plan with you and adjust it based on your needs.
The COPD Transitional Care Team takes a multidisciplinary approach to your health. Members of the team include:
- Nurse practitioner
- Pharmacist
- Transitional care nurse navigator
How the COPD Transitional Care Team Works
First, the nurse practitioner (NP) evaluates you with a pulmonary function test to confirm a COPD diagnosis. When heart failure or another pulmonary issue is the problem, the NP refers you to an appropriate specialist. If COPD is present, the pharmacist gets to work.
The pharmacist evaluates your medication and needs with multiple goals. These include:
- Checking that your COPD medication doesn’t interact with other medications. Drug interactions can cause one medication not to work or cause unwanted side effects.
- Ensuring you’re on the right COPD medication. Depending on your needs, you may benefit from an inhaler, pill or nebulizer. The team helps determine the best choice to treat lung issues you face. Often, the best option is a combination of three medications. In addition, the pharmacist evaluates your non-COPD medications and makes changes if necessary.
- Reviewing your insurance coverage. The team then helps to find affordable medication options. When appropriate, they may suggest a new medication, help get insurance authorization or work with the nurse navigator to enroll you in patient assistance programs to offset the cost of medication. Even if you don’t have insurance, the team can find low-cost options.
Bringing the COPD Care Team Home
Your medical care continues after discharge. Every week, the nurse navigator calls. During this call, the navigator checks in, and you ask questions about your COPD care plan. If your health worsens, the nurse navigator guides you toward improved health, acting as a health care social worker.
Essentially, the nurse navigator provides supportive care, helping you breathe better by taking you through steps including:
- Smoking cessation. Smoking causes and worsens COPD, lung cancer and more. Quitting smoking as soon as possible is the best choice for your health. The nurse navigator points you to resources to stop, including University of Maryland Medical System smoking cessation programs.
- Ongoing education. The nurse navigator helps you stay on track and can help you remember what you learned while you were in the hospital. Then you can put what you learned into practice. If you are prescribed new medications or an oxygen device, the nurse navigator ensures you know how and when to use it.
- Scheduling appointments and tests. Scheduling appointments with a pulmonologist, thoracic surgeon or other specialist can take weeks. With the nurse navigator by your side, most times you get in within days. The COPD Transitional Care Team’s nurse navigator can also talk to you about pulmonary rehabilitation for advanced lung disease and help you sign up for rehabilitation.
- Provide a listening ear. Living with COPD can be stressful. The nurse navigator can listen to your concerns, remind you of tools and techniques for better breathing and help you manage COPD-related stress.
Additionally, the team works to connect with patients who never get admitted to the hospital. When someone with COPD visits the ER, the team gets an alert. They then touch base with the patient, either in the ER or via phone call afterward. This gives more COPD patients access to the COPD Transitional Care Team and improved quality of life.
More to Read
- Should You See a Pulmonologist?
- Pulmonary Rehabilitation: A Breath of Fresh Air
- Nutrition for Lung Health and COPD
- COPD and Exercise: How to Benefit from Staying Active
Medically reviewed by Katrina A. Roux-Bernstein, CRNP.
