Health Care Innovation Awards Round Two: Project Profile


Project Title: "COPD Access to Community Health (CATCH)"
Geographic Reach: California
Estimated Funding Amount: $4,136,499


The Ventura County Health Care Agency project will test implementation of Chronic Obstructive Pulmonary Disease (COPD) Access to Community Health (CATCH), a community-based care coordination program based on the chronic care model. Care coordination activities include: (1) clinical, psychosocial, and environmental assessments; (2) care plan development with the primary care providers (PCPs); and (3) specialist input. The development of the care plan is based on 2013 Global Initiative for Chronic Obstructive Lung Disease guidelines that include: patient education and self-management training; care management; community referral and coordination; home visitation; monitoring and feedback; and follow-up and reassessment. Community outreach will include community education, risk assessment, screening, and referral to PCPs/medical homes. Health internet technology integration and clinical provider/PCP training will be implemented to promote evidence-based practices. The model aims to improve stability of the COPD condition and reduce emergency room visits, inpatient days, and overuse of PCPs. Integration of clinical care guidelines in clinical practice will significantly reduce costs by ensuring patients access the appropriate level of care (nurse, PCP, pulmonologist or other specialist) for their condition.

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