By Anthony J. Billittier IV, MD, Chief Medical Officer

Last quarter, I reported plans to launch a Chronic Obstructive Pulmonary Disease (COPD) Medical Neighborhood Pilot.

To briefly re-cap, a COPD-focused “Medical Neighborhood” is led by the Primary Care Physician/provider and takes into consideration all the attributes a COPD patient needs to maintain stability; both medically and socially. For example, the COPD Medical Neighborhood may need to include several specialists in key areas such as Pulmonology; Respiratory, and Behavioral Health. And depending on the social determinant of health challenges the patient may be experiencing; important linkages may also need to be established with Home Care and Community-Based Organizations.

Bringing all key elements efficiently together requires the development of a care plan involving all Medical Neighborhood participants; and then coordinating that agreed upon plan through Primary Care with an abundance of bi-directional communication so all caregivers know what is happening with the patient as close to real time as possible. Ultimately, it’s all about the Primary Care lead knowing who the referral sources are within the Neighborhood so when an incident arises and a phone call comes in about the patient, Primary Care can activate systems of care more readily.

   

The framework for the COPD Medical Neighborhood Pilot initiative continues to evolve on several fronts. We have engaged Millennium’s new Care Coordination Support Team to assist with COPD projects taking root at three Primary Care organizations — The Chautauqua CenterECMC Grider Family Health Center, and ECMC Internal Medicine. Initial work at these practices involve defining and implementing diagnostic standards, environmental controls and new workflows; solidifying relationships with practice-specific Medical Neighborhood partners; and establishing bi-directional communication processes with them.

We have also continued to communicate/distribute the Gold Standards of Care, and due to continued demand, are pleased to continue to make the handbook on “Global Initiative for Chronic Obstructive Lung Disease” available. Please click HERE to access a personal copy.

Lastly, we are developing further education in the form of a comprehensive webinar program that will be focused on the implementation of a “COPD-Focused Medical Neighborhood.” The target audience includes our COPD Work Group in addition to Behavioral Health, Community Based Organizations, Primary Care, Hospitals, and Post-Acute/Home Care. The ultimate objective of this MPA deliverable is to communicate critical information needed to successfully manage a COPD patient outside hospital walls. Please watch for an invitation to our COPD Medical Neighborhood webinar in the coming weeks.

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