The Power of Partnership: Improving services for patients with COPD in Guelph

A story of collaboration across the health system


Imagine feeling completely out of breath during even the simplest tasks like walking up a flight of stairs or taking the dog for a walk. For patients with COPD, this is a reality. Usually diagnosed after the age of 40, there is no cure for COPD. However, early diagnosis, the right medication, and a comprehensive care plan can make a healthy and active lifestyle possible. Care providers in Waterloo Wellington know this and set out to help people living with COPD to live healthier and happier lives.


The vision began two years ago when care providers from Guelph General Hospital, Guelph Community Heath Centre, Guelph Family Health Team, St. Joseph’s Health Centre Guelph, Home and Community Care, came together to form a COPD Steering Committee aimed at developing a much more collaborative approach to patient care for people with COPD.


The first step was working together as partners with patients and caregivers to identify the current patient journey, the needs of patients with COPD and to co-create an improved patient pathway. Through this extensive consultation, guiding principles and a client value statement were developed that place the following as the anchor for shared work across the health system: patients want to be part of the decisions about their care, to understand the options and their outcome, to be respected for their decisions, and to have timely access to the best care and supports to improve their quality of life.


With this input from patients and caregivers, the committee went to work to design “Dedicated Care Pathways” to improve care for patients in Waterloo Wellington. Part of this exercise included empathy mapping (pic. 1) through which patients and care givers described their experiences of living with COPD.



Improvements made so far through the partnership’s efforts include:

  • A new standardized admission and discharge processes in hospital,
  • Improved communication with all care providers,
  • Primary care follow-up appointments that are booked prior to discharge,
  • Rapid Response Nursing supports to patients in their homes immediately following discharge,
  • Engaged physicians identify patients that need follow up
  • Primary care working closely with hospitals to identify high risk patients to ensure proactive management, early diagnosis, education and self-management support to individuals with COPD, and the leveraging of technology tools such as custom forms and dashboards to support the work.
  • Trying new ways of supporting patients in their homes with technology that measures key vital signs (oxygen, etc.) and sends information to care providers (nurses and EMS) so follow up can happen remotely or in person as needed.


One of the main objectives of this work is to decrease re-admission rates to hospital for those with COPD.  When this program began, COPD re-admission rates were 26.5%. They are now sitting below 14.26% with zero re-admission rates in the month of August. This success was as a result of true collaboration across the healthcare system.


The COPD Steering Committee continues to work diligently to ensure their vision of improved quality of life and a better care experience becomes a reality for everyone living with COPD in Waterloo Wellington.


For more information on COPD click here.