Primary Care Management/Action Plans for Advanced Chronic Diseases
Primary Care Management/Action Plans for Advanced Chronic Diseases
Patients living with advanced chronic diseases (ACD), such as congestive heart failure (CHF)
 and chronic obstructive lung disease (COPD) present substantial care and economic challenges
 for the health care system due to frequent emergency room visits and acute care
 hospitalizations. Morbidity and mortality is high in these complex populations, and patient
 quality of life is often compromised.

 Care of patients with ACD occurs across health care sectors, by providers in the acute,
 primary and community settings. Despite recent efforts to enhance the care of patients with
 ACD, through multidisciplinary disease management programs, variations and gaps exist along
 the continuum of care. The available evidence suggests that there are opportunities to
 optimize the primary care of patients with ACD. We are proposing to build upon the current
 evidence and guidelines for disease management programs, our existing specialized resources,
 our existing primary care practices, and develop and test a model of care that is primary
 care based, sensitive to the unique demands and characteristics of different primary
 practices. Our goal is to design linkages and care strategies of relevance and importance to
 the primary care providers who care for patients with advanced COPD and CHF.

 This demonstration project is a randomized controlled clinical trial of the RoadMAP program
 (intervention) delivered by a Primary Care Nurse Specialist (PCNS) compared to usual care
 (control group). The primary outcomes will be degree of adherence to clinical practice
 guidelines. Secondary outcomes will be patient satisfaction, quality of life, use of
 community-based services, number of emergency room visits, and number of hospitalizations.
The available evidence suggests that there are opportunities to optimize the primary care of
 patients with ACD. We are proposing to build upon the current evidence and guidelines for
 disease management programs, our existing specialized resources, our existing primary care
 practices, and develop and test a model of care that is primary care based, sensitive to the
 unique demands and characteristics of different primary practices. Our goal is to design
 linkage and care strategies of relevance and importance to the primary care providers who
 care for patients with advanced COPD and CHF.

 The study is a randomized controlled clinical trial of the RoadMAP program (intervention)
 delivered by a PCNS compared to usual care (control group). The primary outcome will be
 degree of adherence to clinical practice guidelines. Secondary outcomes will be patient
 satisfaction, quality of life, use of community-based services, number of emergency room
 visits, and number of hospitalizations. The purpose of the RoadMAP program is to improve the
 care of people with advanced stage COPD and CHF. Specifically, activities will be aimed at
 improving patients' self care ability, facilitating access to the most appropriate services,
 ensuring medical treatment according to consensus guidelines and promoting consistency of
 health care communication. Adherence to guidelines is a process that involves activities by
 the patient, PCNS, and the Primary Care Physician. The PCNS would follow-up the patient again
 at approximately one month after initial contact and then every 3 months, to assess and
 monitor adherence to the proposed MAP by the patient, the physician, and the nurse. Patients
 will have the option of returning to the physician office or to be monitored by phone. An
 office visit will be recommended if there is a perceived need for medical assessment and
 intervention. The family physician would continue to see the patient as required in order to
 carry out the medical portion of the MAP and to deal with other primary care problems as
 needed. Additionally, the PCNS would be available to work with nurses and other health
 professionals in each primary care practice in the provision of care to the ACD patients.
Inclusion Criteria:

 -  diagnosis of Chronic Heart Failure

 -  diagnosis of Chronic Obstructive Pulmonary Disease

 Exclusion Criteria:

 -  living in a nursing home

 -  inability to give informed consent

 -  involved in other studies of CHF or COPD