Abstract
Background: It is estimated that by 2030, COPD will be the 3rd leading cause of death worldwide, representing a 30% increase in COPD-related mortality compared to 2002 (WHO, 2016).
Approach: The impact of respiratory diseases has motivated several global initiatives aimed at optimizing the response to this problem. Among others, the United Nations has set 2030 target 3.4 of the Sustainable Development Goals to reduce premature mortality from non-communicable diseases by one third, including respiratory diseases, through prevention and treatment. Among these diseases, Chronic Obstructive Pulmonary Disease (COPD) is the most prevalent and poses numerous challenges in its diagnosis and treatment. Despite the epidemiological trend, the organization of care for COPD continues to be oriented towards the acute disease, with a reactive and episodic response, with institutions operating in silos, not responding to the needs of people with chronic diseases, many of them complex, which inevitably consume more health, social and community resources. The involvement of the person/caregiver in the approach to people with multimorbidity must be integrated, promoting coordination, transition and continuity of care throughout their care pathway. The CONSIGO Integrated Care Program is a multidisciplinary healthcare approach based on a value-based healthcare model, centered on self-efficacy and quality of life. It is developed in a context of opportunities and great technological development in healthcare, namely the existence of recent, valid and reliable guidelines, guiding documents for the implementation of COPD intervention programs, being implemented in an organization with favorable conditions for the integration of care and the development of proximity care, the existence of motivated human resources, and, the existence of physical and safety conditions for its implementation. It seeks to combine several complementary approaches in an integrated way, namely, the development of awareness-raising activities for COPD in the community, which are fundamental for preventing the disease, the existence of an Integrated Care Pathway for People with Multimorbidity, which is fundamental for the early identification, assessment and signposting of people with COPD, as well as for promoting communication between the different players and acting proactively to stabilize the disease, the existence of a Spirometry Network and a Respiratory Rehabilitation Programme with a multidisciplinary approach, preferably decentralized, which is essential for early diagnosis, disease stratification and the overall empowerment of the person and caregiver to self-manage the disease, the development of telehealth at a local level, which is particularly important for reducing geographical inequalities in access, and the partnership with people with COPD in building and adapting the programme to their needs.
Results: This program its in a early fase of implementation but we hoppe to present it´s first results at ICIC 2025
Implications: With this program, we intend to contribute to an improvement in disease incidence indicators through community prevention actions and support for lifestyle changes, improve community literacy about COPD, improve the quality of life of people with COPD and caregivers by empowering them to self-manage their chronic disease, and contribute to an effective stabilization making the whole system more sustainable.