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Quality Statement 3 - Goals of Care and Individualized Care Planning

People with COPD discuss their goals of care with their future substitute decision-maker, their primary care provider, and other members of their interprofessional care team. These discussions inform individualized care planning, which is reviewed and updated regularly.

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Change Ideas:
Provide clinicians with resources to support discussions surrounding goals of care and individualized planning.

The CTS COPD Action Plan is a written contract between patients and their health care team. It will tell you how to manage your COPD flare-ups and will help patients to quickly recognize and act to treat flare-ups.

Toolkit of COPD digital resources to help patients and their families and caregivers learn more about COPD, including risk factors, signs and symptoms, treatment options, and more.

E2P’s EMR-integrated COPD tool for TELUS PS Suite or Accuro QHR supports primary care by giving them easier access to information they need at the point of care.

Leverage electronic health information sharing platforms and portals that support integration of care and communication between care teams.

The Ocean Healthmap is a comprehensive, map-based directory that makes it easy to search and access health care services. In collaboration with provincial health care systems, the Healthmap is actively maintained and updated, empowering providers to make more informed care decisions.

SCOPE (Seamless Care Optimizing the Patient Experience) is a virtual, inter-professional care team that connects primary care providers to specialists, hospitals, community care and mental health resources in real-time.

Virtual care helps people access the care they need when and where they need it. We work with our partners to find better value for Ontario’s publicly funded health care system.

Electronic Referral (eReferral) simplifies the referral process by enhancing communication between primary care clinicians and specialists/organizations and enabling quick and secure referrals to be sent and received through an electronic platform.