Chronic Care Management

Personal Health Communication, Transfer of Care, Coordination of Care. see Use Case Categories

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Mr. W has been followed by a home care agency for many years due to his severe COPD and emphysema and use of Oxygen at home. The intensity of the services has varied over time. He is able to perform the basic activities of living independently but on some days his fatique and dyspnea are too severe to perform all necessary activities. On those days he stays in his pyjamas, watches TV and sleeps sitting upright in a chair. Weather permitting and if he feels up to it, he goes outdoors for a walk with his oxygen hooked up to a wheeled walker. He sits to rest whenever he needs to but generally his distance walked has increased. Six months ago he underwent an outpatient pulmonary rehabilitation program that included self-care management, exercises and health promotion. He was also started on a new regime of medications including instructions for early intervention. Since the program ended 3 months ago, he has had only one urgent visit to his physician but no Emergency Department visits and no overnight hospitalizations. This represents a marked improvement over previous 3 month periods in the past 2 years where he averaged 2 ED visits and one hospitalization. His wife also reports that she now assists him for about 8 hours per week whereas previously her total hours were 14 per week. She is feeling less overwhelmed. His self rating of health is also higher- very good as compared with poor or fair in previous assessments. He is keeping up with his exercises at home and walking outdoors when possible, overall having about 2 hours of exercise in the past 3 days. He has gained about 5 pounds in the last 3 months that appears linked to greater intake of food not edema.