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COPD Program
The highest incidence of COPD occurs among individuals who smoke or have a history of tobacco use. An estimated 16 million adults in the United States are affected by this condition.
Frequent exacerbations of COPD are a leading cause of hospital readmissions and can lead to long-term declines in lung function, deterioration in overall health status, and a reduced quality of life.
To address these challenges, St. Tammany Health System's Transitions of Care COPD Program offers a home-based, patient-centered approach focused on education, assessment, management and care coordination. The program includes home visits by nurse practitioners and registered nurses, telehealth consultations, and regular telephonic follow-ups to support a seamless transition from inpatient care to home recovery.
Read on for more information on how the program works.
1. ASSESSMENT AND EVALUATION
Assessment with the COPD program begins while inpatient with the program’s nurse navigator and is continued into the patient’s home with provider and nursing visits.Evaluation of a COPD exacerbation is an ongoing process that involves a thorough physical assessment, assculation of lung sounds, vital sign review, and medication compliance. That is followed by ongoing and “as-needed” assessments.
Assessment with the COPD program begins while inpatient with the program’s nurse navigator and is continued into the patient’s home with provider and nursing visits.
Evaluation of a COPD exacerbation is an ongoing process that involves a thorough physical assessment, assculation of lung sounds, vital sign review, and medication compliance. That is followed by ongoing and “as-needed” assessments.
2. CONDITION MANAGEMENT
Effective COPD management focuses on reducing the frequency and severity of exacerbations while improving daily symptom control. Core strategies include individualized medication plans, smoking cessation support, pulmonary rehabilitation enrollment and regular monitoring to track disease progression.After hospital discharge, the COPD care team conducts comprehensive in-home evaluations, which include a review of your medical history, a full physical exam, medication reconciliation, coordination of lab and imaging orders as needed, and identification of environmental or lifestyle factors that may impact your respiratory health. The team also evaluates your understanding of COPD management and provides personalized education on medication use and lifestyle changes. This proactive approach is designed to optimize treatment, reduce readmission risk and support long-term self-management. Through a combination of home visits, telehealth consultations and regular phone check-ins, our COPD team provides continuous support and care coordination to help patients stay on track with their treatment plan and remain safely at home.
Effective COPD management focuses on reducing the frequency and severity of exacerbations while improving daily symptom control. Core strategies include individualized medication plans, smoking cessation support, pulmonary rehabilitation enrollment and regular monitoring to track disease progression.
After hospital discharge, the COPD care team conducts comprehensive in-home evaluations, which include a review of your medical history, a full physical exam, medication reconciliation, coordination of lab and imaging orders as needed, and identification of environmental or lifestyle factors that may impact your respiratory health. The team also evaluates your understanding of COPD management and provides personalized education on medication use and lifestyle changes.
This proactive approach is designed to optimize treatment, reduce readmission risk and support long-term self-management. Through a combination of home visits, telehealth consultations and regular phone check-ins, our COPD team provides continuous support and care coordination to help patients stay on track with their treatment plan and remain safely at home.
3. PREVENTION
By enrolling in the St. Tammany Parish Health System COPD care bundle, you gain access to a comprehensive, multidisciplinary approach to managing your condition. This team includes nurse practitioners, registered nurses and respiratory therapists, all collaborating to provide the best possible care.Key components of the program to prevent COPD exacerbations include:
By enrolling in the St. Tammany Parish Health System COPD care bundle, you gain access to a comprehensive, multidisciplinary approach to managing your condition. This team includes nurse practitioners, registered nurses and respiratory therapists, all collaborating to provide the best possible care.
Key components of the program to prevent COPD exacerbations include:
Medication adherence and proper use: Consistent use of prescribed maintenance medications is essential in preventing hospitalizations due to COPD exacerbations. It is critical to take your prescribed medications regularly and use inhalers correctly to effectively manage symptoms and prevent flare-ups. Early intervention for exacerbations: Prompt recognition and treatment of early-stage exacerbations, including medication adjustments and necessary workups, can help prevent hospitalization and reduce symptom severity. The COPD team will give you a magnet to refer to for guidance on when to report respiratory symptoms. Smoking cessation: Quitting smoking is one of the most effective ways to slow the progression of COPD and reduce the frequency of exacerbations. Pulmonary rehabilitation programs: These programs improve exercise capacity, alleviate symptoms and slow the decline in lung function, all contributing to better overall health and quality of life.
This coordinated care approach is designed to help you manage your COPD more effectively, reduce the risk of exacerbations, and enhance your overall well-being.
4. COORDINATION OF CARE
One of the main roles of your COPD program team is to effectively communicate your treatment plan to you as the patient and coordinate all providers who are participating in your treatment plan. This includes:
5. ONGOING MONITORING
Following the initial home visit by the nurse practitioner and registered nurse, you will continue to receive weekly check-ins from our care team. Additional follow-up visits will be scheduled as needed to manage the symptoms of your chronic condition over a 90-day period. At the end of our services, we will assess whether a referral to palliative care is beneficial for ongoing symptom management. Additionally, we offer remote patient monitoring to track your vital signs daily, allowing us to quickly identify any abnormalities and intervene early to prevent complications.
Following the initial home visit by the nurse practitioner and registered nurse, you will continue to receive weekly check-ins from our care team. Additional follow-up visits will be scheduled as needed to manage the symptoms of your chronic condition over a 90-day period.
At the end of our services, we will assess whether a referral to palliative care is beneficial for ongoing symptom management. Additionally, we offer remote patient monitoring to track your vital signs daily, allowing us to quickly identify any abnormalities and intervene early to prevent complications.
Your St. Tammany Health System Transitions of Care COPD program team. (STHS image)
Remote patient monitoring uses digital devices such as a blood pressure cuff, pulse oximeter, scale and tablet to collect daily vital signs. These vital signs are monitored daily by a registered nurse to detect early warning signs of a CHF or COPD exacerbation.
Vitals signs are transmitted to St Tammany Transitional Care office and reviewed 7 days a week. Any abnormal findings are address by one of our nurse practitoners.
Patient’s vital signs can be seen in MyChart by the patient and other healthcare providers. Remote patient monitoring is delivired to your front door and is a quick and simple set up.
Contact us at 985-871-5955 for questions or a referral to St Tammany Remote Patient Monitoring.
A closer look at our program's offerings:
The Transitions of Care Heart Failure program at St. Tammany Health System is a home-care-based program providing specialized care to patients with heart failure for 90 days after discharge from the hospital.
Whether you’ve got a question to ask or an appointment to keep, getting in touch with us is a cinch. Here’s everything you need to know:
101 Ashland Way, Suite 1Madisonville, LA 70447
Phone: (985) 871-5955
Fax: (985) 871-5954
Remote patient monitoring: (985) 871-5978
