Improving Patient Outcomes: A 3-Part Guide to Closing Clinical Care Gaps (Part 1: COPD)


Part One: Patients with Chronic Obstructive Pulmonary Disease COPD

16 million Americans have (COPD), according to the Centers for Disease Control and Prevention (CDC). Although there is no cure, healthcare providers play an important role in helping patients manage their symptoms. The following are ways in which clinical teams can help close care gaps and provide value-based care for patients with COPD:


Leverage technology to identify patients with COPD. Identifying patients with COPD promptly and accurately is crucial for providing effective care and improving patient outcomes. Leveraging technology to identify these patients through point-of-care gap flags is an innovative and efficient approach to closing clinical care gaps. Point-of-care gap flags alert providers to patients who meet certain criteria for COPD, such as a history of smoking, respiratory symptoms, or abnormal pulmonary function test results. These flags can prompt clinicians to conduct further diagnostic tests, refer patients to specialists, and develop personalized treatment plans.


Enroll patients in care management programs such as chronic care management (CCM). Patients with COPD frequently have multiple other chronic, comorbid conditions, making them ideal candidates for CCM. Providing eligible patients with access to a care manager is one of the most effective ways to close care gaps for COPD. With CCM, providers get paid to help patients follow an action plan, take COPD medications correctly, and use other techniques to manage their symptoms.


Follow clinical guidelines and best practices for COPD. Adhering to clinical guidelines and best practices for COPD diagnosis and management (e.g., prescribing a long-acting inhaled bronchodilator for certain patients with COPD) is paramount. So are these lifestyle interventions: Control tobacco use, address environmental exposures, improve prevention/treatment of infections, and promote physical activity and better nutrition.


Focus on patient education. When it comes to COPD, patient education is often lacking. Patients need more information about breathlessness, managing anxiety and panic, pursuing helpful and safe levels of activity, maintaining quality of life, and knowing what to expect in the future. Referring patients to a pulmonary rehabilitation program can be very beneficial. So can iterative communication regarding self-management techniques. CCM programs promote all of this and more to help patients actively manage their COPD.



Leveraging technology to identify COPD patients through point-of-care gap flags enables healthcare providers to streamline care delivery, improve outcomes, and save lives. To close clinical care gaps for COPD patients, an integrated disease management approach that emphasizes frequent touchpoints and patient education is essential. CCM programs can facilitate ongoing communication and make this approach possible. Contact DignifiHealth to learn how we can assist you in this effort.