Integrated care of the COPD patient: a pulmonary rehabilitation perspective

The current acute care model for COPD is, in general, insufficient for optimal management of the disease. Single disease guidelines often fall short for diseases such as COPD that have prominent systemic manifestations and frequent comorbidities contributing to disease burden. Coordination of services is often inadequate, especially at the time of the COPD exacerbation, which is characterised by high morbidity, increased healthcare utilisation and increased mortality risk. The integrated care model for COPD may reduce some of these inefficiencies. On one level, integrated care means giving the right patient the right therapy at the right time. This can include smoking cessation therapies, the promotion of a healthy lifestyle, including regular exercise and increased activity, optimal pharmacotherapy, collaborative self-management strategies, palliative therapy and end-of-life care. Additionally, integrated care improves access to care and reduces fragmentation of care through partnering, communication and coordination among healthcare professionals, patients and their families. Integration at the time of the exacerbation includes a comprehensive assessment of the patient at the time of hospital discharge, proper discharge planning, early discharge services, a self-management plan, sharing this plan with all pertinent healthcare providers, utilisation of a professional for case management and facilitation of the exchange of information with modern information technology. Pulmonary rehabilitation provides many of these services and can be considered a component of integrated care.