This multi-year project is funded through an award from the Health Resources and Services Administration (HRSA). Project COPD Connect partners MaineHealth Care at Home (MHCAH), the Coastal Healthcare Alliance (CHA), Healthy Living for Maine (HL4ME), and MaineHealth respiratory specialists to develop an enhanced model of care. This model integrates home health, palliative care, telehealth, and community outreach services to provide a comprehensive solution to the challenges presented by COPD. Currently, the program supports patients across Knox County with plans to expand to Waldo County in the coming months.

Central to the project is the role of the COPD Navigator. Navigators are employed across the MaineHealth system and function as educators and advocates that guide patients across health care settings and linking them with appropriate community resources.

Heather Lomax, Chief Nursing Officer at MHCAH, believes collaboration with the greater health care community impacts quality of care for our mutual patients. “In home health we recognize that our time in the home with patients is limited. We have a responsibility to be efficient and to seek innovative solutions that increase our capacity toward a more connected experience for patients.”

The palliative care practitioners partnering in the project support the early integration of palliative services. “Improved coordination of community resources is always beneficial to patients. Early and appropriate referral of patients for palliative consultation helps clarify goals of care and support patient quality of life,” explained Karin McDonald, NP.

Project partner, HL4ME, is a statewide Community Care Hub Network offering evidence-based programs and social care services to Mainers through community-based organization and health system partnerships. For this project, HL4ME provides resources to patients through self-management education programs, allowing them to better manage their chronic disease and improve quality of life. Partnering with home health and palliative care providers has provided a unique opportunity “to integrate chronic disease self-management programs into a dedicated model—with nurse navigation services and palliative care—culminating in a truly ‘comprehensive’ model of care for COPD patients participating in the project,” said Maija Dyke, HL4ME Business Manager.

Becoming more patient centered is the ultimate objective. With the goal of improving patient access, satisfaction, and treatment, the effectiveness of this program will be evaluated over the next few years, with the potential to use it as a model for other disease groups.

Heather Lomax

Karin McDonald, NP

Maija Dyke