Chronic obstructive pulmonary disease (COPD)
What is COPD?
COPD or Chronic Obstructive Pulmonary Disease is a long-lasting lung disease that affects breathing making the airways in your lungs become narrower due to inflammation (swelling) and damage. This leads to symptoms like trouble breathing, coughing with mucus, wheezing sounds, and a tight feeling in the chest. Current treatments, prevention methods and lifestyle changes can help manage the symptoms and slow down its progression.
Note: If you’re experiencing any breathing difficulties or persistent coughing, it’s a good idea to talk to a physician who can provide proper guidance and support.
Our vision
The COPD Working Group seeks to ensure that patients receive quick and improved access to pulmonary rehabilitation right after a severe COPD flare-up. Additionally, the group aims to make it easier for patients to move from the hospital back to their homes smoothly.
What we’re doing
The COPD Working Group is currently working on a detailed review of patients with COPD to better understand where there might be gaps in their care, how they are referred for treatment, what patients and their caregivers need, and how much the care costs.
The plan of the Working Group is to improve the way people with COPD are taken care of in West Toronto. This includes getting people who live with COPD better at-home support, having nurses respond quickly, using tele-home care, and giving patients the same standardized information about their condition.
A Care Manager role within the care team will focus on COPD patient care during the transition from acute care to home care for eligible individuals (will make direct contact with the patient). The Care Manager will:
Helps patients navigate through the system
Develop care plans
Provide ongoing monitoring of the patient at home
Provide in-home nursing visit within 24 hours of hospital discharge
Provide medication reconciliation and education on the patient’s chronic condition and coping mechanisms to help maintain independence and ensure quality of life is supported
Work closely with rehabilitation partners to identify the most appropriate rehabilitation program, facilitating the application process and following the patient over a period of 12-14 weeks
Connect patients to community resources
Ensure assessments are conducted
Communicate with Primary Care Providers and specialists
Why are we doing this?
Even though pulmonary rehabilitation is good at helping people with lung diseases, there are problems with how it's done after people leave the hospital. It's not always easy for people to access this care right after leaving the hospital. Medical care that's not well-connected can make it hard to move from the hospital back into the community, which can lead to worsened health conditions, more trips to the hospital, and higher healthcare costs. By bringing together a clear team to work together, we can make sure everyone is on the same page, improve how care is coordinated, and help people get better (fewer visits to the Emergency Department, fewer times in the hospital, and more independence for patients).
Our team
Supporting organizations: