COPD Care Management Plan Example

COPD Care Management Plan


A care plan is a necessary tool for the Patient’s recovery journey. It should address all issues that a patient faces to create an effective care strategy that is important to get the Patient back to a healthy state. A care coordination plan allows integration and collaboration of service that connect people to health care service that meets individuals’ needs (Mayorga & Deering, 2017). For individuals with chronic diseases, a care plan comes in handy in managing the disease as it allows them to have a better quality of life. Also, it is vital as it reduces health costs from avoidable complications that may arise. Therefore, with this understanding, the purpose of this paper is to develop an effective care plan for addressing health issues and challenges that may face a hypothetical chronic obstructive pulmonary disease patient. Also, there will be a discussion on essential goals that are vital in achieving the desired goal of the care plan. The care plan will also focus on analyzing community resources that are of importance in Important continuum care.

Pulmonary disease

Chronic Obstructive Pulmonary Disease is a lung disease that causes a person to have difficulties breathing due to blocked airways (Ranzini, Maestri &  Bertolotti, 2017). Complications from COPD can be life-threatening which can result from death due to shortness of breath. COPD exposes patients to a variety of complex health issues that requires more than just pharmacological interventions. This is why patients with COPD require an effective care coordination plan as it helps develop strategies that help eliminate life-threatening complications. COPD patients require an integrated care plan that connects patients, health care providers, and families as an integral part of creating a coordinated care plan (Mayorga & Deering, 2017).

The Goal of the Plan

According to the journal of Chronic obstructive pulmonary disease, the best care plan practices for COPD patients are pulmonary rehabilitation, integration of care, care transition to the care model, and adopting a holistic approach. This goal allows patients to meet the complex needs of COPD patients through proper management. Due to the nature of COPD and the unpredictability of complications that may arise from it, it hasn’t proven easy to manage it. This is because dealing with comorbidities for severely affected patients can be most challenging due to the hopelessness of the condition (Mayorga & Deering, 2017). Also, some patients do not respond well to the treatment plan because of the different complexities that arise.

Community Resources

COPD patients should take advantage of community resources that are readily available and could help stimulate the care management plan (Dickens & Adab, 2017). In this case, COPD patients should engage in community resource centers that offer yoga, muscle relaxation programs, and deep breathing exercise programs.

Care Coordination Plan

The primary purpose of a care plan for this hypothetical Patient is to achieve maximum cooperation in COPD management. Also, it sheds light on the disease, creates a comprehensive self-management support program, guideline-based management, and rehabilitation program (Ranzini, Maestri &  Bertolotti, 2017). To achieve a comprehensive and effective care plan for Patient XYZ, there will be a team of 7 COPD professions. A team of seven is diverse, and each member has unique expertise and vast knowledge on the management of COPD. This team will have two pulmonologists, a researcher, a nurse, two general experts, and a family member. Below is a care coordination plan for Patient XYZ.

Preliminary care management plan for Patient XYZ

Name of the Patient: Patient XYZ

Telephone number: XXXX

Resident Address: XXXXX block 4

Self-management behavior

  1. Medication adherence- To prevent execration and improve activity tolerance in day-to-day life and instances of dyspnea admission to the hospital because of complications and treatment failure (Dickens & Adab, 2017). Take:-
  2. prednisolone 30mg daily
  3. albuterol 100/20 mcg every six hours at a maximum of 6 times a day.
  4. ciprofloxacin twice a day
  5. Improving exercise and physical activity level
  6. Retrain breathing using coordinated intervals

The medication will be collected in the Walmart pharmacy near you.

Adherence score scale


Patient education

  1. For improving exercise and the physical activity level, you will attend muscle relaxation technique at the community resource center.
  2. Attend smoking cessation program at the community resource center
Smoking cessation program  
Muscle relaxation training  

The rating score of the program

ProgramsHighly DissatisfiedNeutralHighly satisfied
Smoking cessation program   
Relaxation technique program   
  1. Influenza Vaccination

Pick a day before the end of the week and take the influenza vaccine. With COPD, you can get seriously ill from the flu (Ranzini, Maestri &  Bertolotti, 2017).

  • Integration of the family

This is an integrated care management plan, and for it to be successful, there is a need for family intervention. The central role of the family is for psychological and emotional support. Also, the family will assist us in providing care to you.

It would be of best interest if your spouse could join you in the patient education programs and daily.

The collective effort and integration of each party involved in creating this care plan will yield more positive results and achieve the best care management for Patient XYZ.

Care coordinator 
Care plan Physician 
Walmart Pharmacy 
Local Community Resource Center 
Local Clinic 


Dickens, A. & Adab, P. (2017). Self-management behavior and support among primary care COPD patients: a cross-sectional analysis of data from the Birmingham Chronic Obstructive Pulmonary Disease Cohort. NPJ primary care respiratory medicine, 27(1), 1-10.

Mayorga, V., and Deering, K. (2017). Prevalence of low peak inspiratory flow rate at discharge in patients hospitalized for COPD exacerbation. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 4(3), 217.

Ranzini, L., Maestri, R., &  Bertolotti, G. (2017). COPD patients’ self-reported adherence, psychosocial factors and mild cognitive impairment in pulmonary rehabilitation. International journal of chronic obstructive pulmonary disease, 12, 2059.