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The COPDnet integrated care model

Authors Koolen EH, van der Wees PJ, Westert GP, Dekhuijzen R, Heijdra YF, van 't Hul AJ

Received 4 September 2017

Accepted for publication 4 March 2018

Published 19 July 2018 Volume 2018:13 Pages 2225—2235


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Dr Richard Russell

Eleonore H Koolen,1 Philip J van der Wees,2 Gert P Westert,2 Richard Dekhuijzen,1 Yvonne F Heijdra,1 Alex J van ’t Hul1

1Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; 2Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands

Introduction: This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options.
Theory and methods: The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems.
Results: An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care.
Discussion: In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care.
Conclusion: Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.

Keywords: COPD, COPD management, integrated care, Chronic Care Model, health status

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