title: Integrated care model with self-management in chronic obstructive pulmonary disease: from family physicians to specialists.
abstract: Patient with chronic obstructive pulmonary disease (COPD) has to become a partner and an active participant in his own care, that is, disease self-management. The goal of this article is to present successful and unsuccessful interventions using patient self-management and to propose a model of integrated care more suitable to the needs of COPD patients. This is a narrative review and an opinion article. Many systematic reviews have shown positive outcomes for patients with COPD. These studies have in common a self-management intervention including an action plan in the event of an exacerbation embedded in an integrated health-care system coordinated by a case manager for educational sessions and regular communication. Recently published trials have brought controversy with respect to the effectiveness of self-management programmes, especially in patients with high burden of disease and co-morbidities. It may be more challenging to make the patient with high burden of disease a partner and not without risk of serious adverse events. Finally, our health-care delivery has to be well integrated and more coherent, that is, strategic alliance between primary and secondary care, and supported by interdisciplinary teams for patients with high-risk and complex COPD. Clinical practice has to be structured to address COPD throughout the disease spectrum, that is, secondary versus primary, team work, partnership, self-management and continuity of care.
authors: Montreal Chest Institute, McGill University Health Centre, Montréal, Québec, Canada. jean.bourbeau@mcgill.ca
authors: Jean
authors: J
authors: Bourbeau
authors: Nathalie
authors: N
authors: Saad
mesh_terms: D003266:Continuity of Patient Care; D019033:Delivery of Health Care, Integrated / Q000379:methods; D005194:Family Practice / Q000379:methods; D006801:Humans; D010348:Patient Care Team; D011320:Primary Health Care / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D015272:Pulmonary Medicine / Q000379:methods; D063127:Secondary Health Care / Q000379:methods*; D012648:Self Care / Q000379:methods*