Three Essential Management Strategies to Comprehensive Care for COPD Patients

November 14, 2019

Dody Fisher, MD

16 million people in US suffer from COPD  

Chronic Obstructive Pulmonary Disease (COPD) is a life-altering chronic condition that plagues many Americans and is the third leading cause of death in the U.S. More than 16 million people carry the diagnosis and up to 75% of patients may still be undiagnosed. Medical costs directly attributed to COPD in the U.S. are increasing and are estimated to be $49 billion by 2020. A large percentage of these patients have co-morbidities such as cardiovascular diseases and metabolic conditions which have a greater negative impact on these patients and makes management more challenging.

There are huge problems with access to standard of care for some of our most vulnerable patients. COPD is universally underdiagnosed and thus undertreated. Given the high comorbidities of this population a truly integrated and holistic approach is needed in diagnosing and treating these patients.

Because of its progressive nature, it is important to diagnose COPD as early as possible and initiate appropriate management strategies. Here are three essential ingredients to a comprehensive care program for COPD patients:

  1. Diagnosing the right patients. Sophisticated patient selection and predictive analytics tools can identify patients with chronic conditions who could benefit from the more intensive approach a house calls program affords in addition to regular care from their primary care providers (PCPs).
  2. Time + relationship + education = better respiratory disease management. While PCPs play a critical role in identifying and managing COPD, patient factors such as transportation challenges, cultural barriers, and environmental issues may hinder clinical assessment. Leveraging close patient-provider relationships in patients’ homes affords providers a unique position to identify contributing factors and improve patients’ adherence to COPD maintenance treatment.
  3. Sometimes simple interventions have a big impact. With condition-specific action planning for every patient, including addressing social and environmental factors that contribute to poor patient outcomes, exacerbations and hospitalizations can be reduced. For example, a social worker can address environmental issues in the home (e.g. mold, pets, etc.) that can make chronic lung problems worse.

Vively Health has incorporated these three concepts into our clinical pathway for patients with COPD. Our care teams treat COPD patients, who often have multiple, interrelated chronic conditions, in the home through routine house calls with 24/7 support. We take full risk in our partnerships and we do not pass along any cost to our health plan partners or their members. 

To learn how Vively can improve the patient outcomes and cost of care for your highest-risk members, contact Ian Laird, National Vice President of Growth. 


Dorothy "Dody" Fisher
National Medical Director, Vively Health