Grant: Project Grant

In Canada, 75% of seniors have one or more chronic conditions, with the majority managing two or more conditions. Chronic Obstructive Pulmonary Disease (COPD) results in almost 50% of chronic-disease related hospitalizations, often complicated by other co-existing conditions such as depression and cognitive decline. Evidence has shown that e-health can help providers coordinate patient care, and evaluate patient social and health needs over time to help them effectively self-monitor symptoms and better self-manage their disease, and avoid deterioration in health and the necessity of hospital-based care. However, the ideal approach to integrate, scale up, and maintain a technology supported care delivery system is unclear. The urgency to adopt and appropriately evaluate e-health will grow as the number of individuals with multiple chronic conditions straining already scarce healthcare resources increases. This research project aims to use e-health technologies to empower patients to develop the skills and confidence needed to manage their COPD. The project will implement and evaluate patient-centered interventions that will provide personalized behavior change support to patients to help them increase their knowledge and skills in managing their health and communicating with their care providers. We developed a patient health portal that will provide patients motivational guidance and automated feedback and messages from a case manager. For care providers, including family physicians and nurse case managers, we will develop a web-based decision support system that will help them administer evidence-based behavior change strategies for their patients with COPD. We will evaluate the impact of this intervention on reducing emergency department and hospital visits, and improving individuals health behaviors. We will also evaluate the implementation of the intervention in primary care.