Pomeranian model of integrated care


Pomeranian model of integrated care for patients with advanced COPD
The aim of the project is to reduce the number of exacerbations and costs of care, and to improve the quality of life of patients with advanced chronic obstructive pulmonary disease (COPD).

The key value of the project is to achieve medical and economic benefits beyond the levels achievable with standard care for patients with advanced COPD. The integrated care model proposes coordination of medical activities, integration with social assistance and home support for patients. An important element of the program is individual and group education of patients and their relatives. The results of the studies conducted so far indicate that the adopted program significantly reduces the number of COPD exacerbations, reduces the overall costs of care (including hospitalization) and is fully accepted by the patients covered by it.

The project
COPD is one of the most common chronic diseases. Exacerbations, the number of which increases with the advancement of the disease, significantly worsen its course. The costs of medical care for patients with advanced disease amount to 80% of the total funds allocated to treatment in this group of patients. Standard care for patients with COPD does not take into account the factors of failure to cope with the disease and is not coordinated or integrated with social assistance.

This leads to a situation of “the patient being lost in the health care system” and not following medical recommendations, which increases the risk of a worse course of the disease and deterioration of the quality of life. Research conducted by the Polish Society of Lung Diseases (PTCD) indicates that a significant unfavourable factor is the lack of knowledge about COPD both in the general population and among patients.

The Pomeranian model of integrated care for patients with advanced COPD was introduced in 2010–2012 in order to reduce the number of exacerbations and costs of care and improve the quality of life of patients with advanced COPD. Its unique value lies in adding additional low-cost procedures to the standard COPD treatment, which increase the effectiveness of treatment, especially in reducing the number of exacerbations (including those requiring hospitalization). An additional value is the demonstration of the possibility of its implementation and development during the operation including the definition of standards for the operation of integrated care and the creation of educational programs for medical personnel, social workers and patients.

The innovative procedures introduced in the model include home patient support, the integration of the medical team with social assistance, and the participation of a coordinator.
In addition to treatment in accordance with the standards and individual needs, patients with advanced COPD are supported in the implementation of recommendations and their fulfilment is monitored. Patients who experience frequent exacerbations and who cannot cope with the disease are offered the help of an assistant at home. In addition to standard specialist medical care, consultations with a psychologist, physiotherapist and dietitian are available, and – if necessary – social assistance. All activities are coordinated by a dedicated person (coordinator). The project involves extensive education. As a result, the involvement of patients who created the Gdańsk Society of COPD Patients has increased.

Next steps
The results obtained so far indicate that the introduction of the model allowed for a significant improvement in indicators of the quality of care. Number of patients treated avoiding one severe exacerbation (NNT) 2.6 (Damps-Konstańska I et al. 2015). Most of the procedures (primary health care, AOS, hospitalization) are financed under a contract with the National Health Fund. Additional costs – coordination of care, education and visits of assistants to sick homes are financed from local government funds and other sources.

The results of the analysis in the 6 months before and 6 months after the introduction of integrated care showed a significant reduction in direct medical costs related to COPD. By reducing the number of exacerbations requiring hospitalization or an emergency room visit, the overall costs have also decreased (Bandurska E et al. 2017, Bandurska E et al. 2019).

As part of the project, cooperation was established with the local government and non-governmental organizations – the Polish Society for Health Programs and the I like to help Foundation. The development of an integrated care system for patients with advanced COPD has become one of the activities implemented by the Health for Pomeranians and the Pomeranian Partnership for Integrated Health Care. In cooperation with the Geriatrics Center of the University Clinical Center (UCK) in Gdańsk, telerehabilitation of seniors was developed and implemented.