D: Develop support network and self-management plan

COPD imposes handicaps which affect both patients and carers ^{238, 239,113, 240} [evidence level II]

In the early stages of disease, patients with COPD will often ignore mild symptoms, and this contributes to delay in diagnosis. As the disease progresses, impairment and disability increase. As a health state, severe COPD has the third-highest perceived “severity” rating, on a par with paraplegia and first-stage AIDS.²⁴¹ Depression, anxiety, panic disorder, and social isolation add to the burden of disease as complications and comorbidities accu­mulate. Patients with COPD often have neuropsychological deficits suggestive of cerebral dysfunction. The deficits are with verbal and visual short-term memory, simple motor skills, visuomotor speed and abstract thought processing.

People with chronic conditions are usually cared for by partners or family members. Significant psychological and physical consequences occur in carers of patients with chronic diseases. In populations where the patient’s chronic disease is non-respiratory, there is evidence ²⁴² that the psychological health status of carers and patients is linked. One of the most effective means of improving the patient’s functional and psychological state is pulmonary rehabilitation.

Health systems around the world are reorienting health care delivery in ways that continue to provide services for people with acute and episodic care needs while at the same time meeting the proactive and anticipatory care needs of people with chronic diseases and multiple morbidities. Wagner and colleagues have articulated domains for system reform in their Chronic Care Model[6]. These include Delivery System Design (e.g. multi-professional teams, clear division of labour, acute vs. planned care); Self Management Support (e.g. systematic support for patients / families to acquire skills and confidence to manage their condition); Decision Support (e.g. evidence-based guidelines, continuing professional development programs) and Clinical Information Systems (e.g. recall reminder systems and registries for planning care).²⁴³ Although these domains are not specifically addressed in the following sections, they are directly relevant to each.

Disease management approaches in COPD include a number of the Chronic Care Model domains. A systematic review by Peytremann-Bridevaux ²⁴⁴ concluded that COPD disease management programs improve exercise capacity and health related quality of life, and reduce hospitalisation. These programs were defined as including interventions with two or more different components (e.g. physical exercise, self-management, structured follow-up) with at least one of these components continuing for 12 months, delivered by two or more health care professionals and incorporating patient education. In this review, it is unclear which specific components of the disease management programs contribute the most benefit to patients.