The Implementing a Novel and Supportive Program of Individualized Care for Patients Living with Respiratory Disease (INSPIRED) program is innovative and evidence-based and uses an integrated approach to disease self-management. It enables exemplary patient and family centered care and support across transitions, for those living with Chronic Obstructive Pulmonary Disease (COPD). The INSPIRED approach is innovative in that it combines home-based COPD education with free, sensitive, advance care planning, neither of which has previously been offered to people with advance COPD in the community setting in Nova Scotia.

Eligible patients are identified during hospital admission, and are enrolled in a program after discharge that provides case management, orchestrated by a skilled respiratory therapist (RT) educator, who also acts as a care coordinator. The care coordinator is supported by other RT educators, a respirologist with expertise in community-based care for patients with advance COPD, and a spiritual care practitioner, to address advance care planning issues.

Patients are followed in their homes with bi-weekly visits for about four months. Emphasis is placed on providing proactive care through home-based self-management for both acute exacerbations of COPD and dyspnea crises, sensitive advance care planning in the home, and help navigating the local healthcare system to gain access to allied support services.

INSPIRED’s mission is to provide and enable exemplary patient and family centered care and support across care transitions for those living with COPD. Two of our primary goals are to improve the quality of life and experience of living with advanced COPD (both for patients and families), by decreasing unnecessary emergency room visits and hospital admissions.

Preliminary analysis revealed that participation in INSPIRED was associated with a 70% reduction in subsequent emergency room visits, hospital admissions and hospital length of stay, for more than 80 patients over six months beyond initiation of the program. Patients reported feeling more confident managing symptoms, less anxious managing stress, and willing to discuss goals of care, including ones related to end of life. There was a 500% increase in Personal Directive completion for INSPIRED patients (60%) versus non-INSPIRED COPD patients (10%).

The money INSPIRED saved the healthcare system in six months is more than three times the annual program costs. This speaks to INSPIRED having larger sustainability for the organization, and is an indicator of success for the program. In a short time INSPIRED has grown from a research initiative to a funded program of CDHA. In the near future INSPIRED is looking to expand its services to the Emergency Department, and to provide more extensive interdisciplinary support within the home setting.

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