VETERANS HEALTH ADMINISTRATION CLINICAL PRACTICE GUIDELINE FOR
THE MANAGEMENT OF COPD OR ASTHMA
Collaborative Self-Management Education: SME Algorithm &
Annotations (D3)
A. Diagnostic Educational
Process
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The patient should be oriented to the diagnostic procedures that have been
ordered, and what the provider hopes to learn from them. It is important
to impress upon the patient:
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Need to participate in the diagnostic procedures
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Implications the results have on proper diagnosis and determining treatments
that improve quality of life
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Alert the patient to key aspects of a pulmonary function test: (e.g., reversibility,
peak flows, the effect of inhaled medicines on changes in spirometry).
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Explain in simple language what the technologist will be doing:
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"You will take a deep breath and blow into a tube. This breathing test
measures how much and how fast air is exhaled."
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"The measurements from the test are used to determine the type, severity,
and the extent to which your lung disease can be reversed."
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Explain how testing will measure parameters before and after bronchodilators,
and that the technologist may teach the initial use of an inhaler with
and without a holding chamber.
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Tell the patient you will discuss the results during the return visit.
B. Has the Patient Completed
the Diagnostic Process?¾ The technologist
augmenting education in the lab (PFT or other) is expected to inform the
clinician of the patient’s education in knowledge and skills, response
and concerns by thorough comments in the medical record. This allows other
team members to build on existing information, and not duplicate work.
Educational components such as medication and inhaler use, use and monitoring
peak flow meters or home oxygen evaluations, if performed as part of the
diagnostic procedure, should be coordinated between the laboratory and
other clinical settings (ED, acute inpatient care, and ambulatory care)
to assure consistent instruction and reinforcement to the patient.
C. Discuss the Importance of
a Diagnostic Workup¾ If a patient
expresses hesitation in participating in workup, including diagnostic process,
lab staff and clinicians should emphasize the importance of the test data
in prescribing effective treatments.
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If the patient fails to make scheduled appointments for diagnostics, follow
up to determine the reason and reschedule.
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If the patient refuses the diagnostic work, then the provider can document
the refusal, attempt to provide minimal medicines, and continually encourage
the patient to return for tests so appropriate treatment and information
can be provided.
D. Clinician/Patient Discuss Diagnosis,
Prognosis, Treatment Plan Options
1. During this initial dialogue, focus on the patient’s concerns, quality
of life, expectations and goals of the treatment (include target dates).
Involve family or other caregiver in the discussion if desired by patient.
Suggested questions to be asked include:
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What worries you most about your COPD/Asthma?
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What do you want to accomplish during this visit?
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What do you want to do that you cannot do now?
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What questions do you have for me?
Focus the discussion on what the patient needs to know (extraneous information
will not be retained and will diminish the emphasis on important content).
2. Does the patient understand the relationship between symptoms (dyspnea,
fatigue, sputum production, wheezing, and other symptoms) and the diagnosis?
3. Explain the disease process in categories of mild, moderate, severe,
according to definitions in the medical algorithms. Most patients can understand
loss of lung function as a percentage of normal. It is very important to
help the patient/family understand the degree of reversibility and the
need for reliever and slow controller medicines as well as the role of
fast relievers.
4. Refer the patient/family to an asthma or COPD class whenever possible
for thorough discussion of the disease process and interventions. If a
referral is not possible, or to provide preliminary information, use educational
materials that reinforce and supplement the discussion of disease processes,
treatment plans and other necessary issues.
E. Implement or Refer for Education
Specific to Medical Treatment
1. SME specific to medical interventions starts on page 11. It is designed
to give all providers the basic elements of what the patient
needs to know to successfully implement the treatment, to augment referral
information and as the basis for course development. Some interventions
will apply to all asthma or COPD patients, some specific to COPD, while
others are specific to individual needs e.g., home oxygen. Each SME segment
is divided into four distinct processes:
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Assessment questions to guide the educator in determining weaknesses and
strengths in knowledge and skills and adherence to plans.
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Information regarding intervention knowledge and skills provided to the
patient/family/caregiver.
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Expected skills and knowledge the patient should demonstrate subsequent
to the information. This is the basis for outcomes evaluation.
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Referral to the medical center experts and community assistance.
2. For ease of access, names are provided in the upper right hand
corner for each intervention, healthy living, or prevention title; they
are also referenced in the CONTENTS.
F. Implement or Refer for Education
Specific to Healthy Living and Prevention¾
The format for SME specific to healthy living starts on page 23. It
is designed the same as the SME for medical interventions.
G. Determine Understanding and
Review Skills Taught in Initial Visit or from Referral
1. Patient understanding, performance and adherence to care plans
should be assessed with each follow-up visit. The assessment may be performed
by any properly trained member of the health care team. The essential information
gained from the assessment is to be shared with the ordering provider to
determine appropriate changes in the treatment plan.
2. To facilitate assessment, the patient should be encouraged to bring
all portable and current medicines, delivery devices, peak flow meter,
symptoms diaries and written treatment and action plans to all follow-up
visits.
H. Does the Patient Understand
the Care Plan ?
1. Adherence to a medicine and treatment plan is greater when the
patient understands what to do, why, and when to do it. It should be expected
that patient understanding of complex plans is evolutionary, dependent
on repetitions and review of key program elements at each follow-up visit.
2. Elements of the treatment and action plans that are not understood
should be reviewed. If the patient is unable to understand upon review,
reassess the patient’s ability to understand. The provider should solicit
information from the patient to determine the following:
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Does the patient understand key elements of the care plan?
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What medicines is patient taking?
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When does patient take it?
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How often, how much and why?
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What does this medicine do?
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What are patient’s expectations from treatment?
3. Refer to the SME for medication and other medical interventions.
DISEASE, MED PLAN, INHALERS, NEBS, ACTION PLAN, MONITOR, EXERCISE, PACE,
CLEAR AIRWAY, O2, or CPAP for further information.
I. Does the Patient Perform Skills Appropriately?
1. Demonstration/return demonstration is an essential component for
teaching all medical interventions requiring psychomotor skills. For example,
when inhalers are used, have the patient demonstrate self-administration
with his or her own medicines, with and without holding chamber. If necessary,
provide placebo and holding chamber for demonstration. Demonstration by
the provider may help to gain the patient’s trust.
2. Can the patient perform key skills where psychomotor function is
required? Recommended trigger/demonstration questions include:
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How do you use your inhaled medicines?
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How do you use your peak flow meter?
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What changes have you made in your activities and eating habits?
J. Is the Patient Adhering to the
Plan?
1. Having established that the patient understands and can perform
skills in the care plan, the next key question is, "Are you doing it?"
Understanding does not equate to adherence. Patients may be unwilling
to admit they have not been following prescribed treatment. Determine which
elements of the care plan, if any, are not being followed. Ask the patient
why. Elements to reconsider when nonadherence is present:
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Language comprehension
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Reading skills
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Visual or hearing problems
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Attention deficit
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Medical and psychosocial factors affecting attention, comprehension or
retention of information
2. Several activities and questions help to determine the level of
patient adherence:
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Review symptom diary
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Review medication use
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Which parts of the treatment plan are most difficult to do?
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What changes might make them easier to do?
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What parts of the treatment plan work best?
K. Is the Management Plan Consistent
with Current Goals?
1. As the management plan changes, the education, to impart the essential
knowledge and skills to support any new interventions, must also be added.
Assessments of the new interventions are expected with every follow-up
visit.
2. The patient’s behavior, comprehension and retention can change over
time. Adherence to care plans improves with regular periodic review of
all elements, with key elements reviewed at each follow-up session.
L. Identify whether this is a Patient
or System Problem
1. System problems¾ unable
to get medicines, not given a care plan, poor access.
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Correct if possible
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Convey information to the appropriate sources with a strong message of
how this problem interferes with patient care
2. Patient problems¾ inconvenient
treatment regime, doesn’t like taste of medicine, medicine side effects,
can’t read plan, forgets to take medicines, denial, and frustration with
care system.
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Enlist a care provider (family, friend, agency or program ) to assist in
the implementation of plan
Module
D2 | Table
of Contents | Module
D4