chronic obstructive pulmonary disease ( copd ) is a progressive and debilitating but preventable and treatable disease characterized by cough , phlegm , dyspnea , and fixed or incompletely reversible airway obstruction.1 only 55% of us outpatients with copd and 33% of copd inpatients receive all guideline - recommended care.2 gaps in care for copd and other chronic diseases do not merely result from underfunding . regions of the us costing medicare the most do not necessarily do better on care quality indicators than less costly , but otherwise similar , regions.3,4 focus on reimbursable procedures rather than evidence - based primary care is often the culprit.3 primary management of chronic diseases requires more integrative  thinking  than technological  doing,5 and is too often underpaid and undervalued relative to its importance to patients.3 superficial remedies , ie ,  just trying harder  and primary care gatekeeping , will not improve patient outcomes6 or cure cost disparities.7 redesign of practice is needed to facilitate proactive primary care of chronic conditions and integrated and accountable delivery of specialty and inpatient services.8 the patient - centered medical home ( pcmh ) is a promising framework for this practice transformation . multiple professions , including physicians , physician assistants , and nurse practitioners , as well as nurses , medical assistants , and registered respiratory therapists , all have roles to play in team - based pcmh care for copd . the pcmh implements , refines , and extends the principles of its predecessor , the chronic care model ( figure 1).9 multidisciplinary team care focused on maintaining wellness , rather than merely reacting to acute illness , is central to the chronic care model and the pcmh.10,11 because providing all current guideline - recommended care to patients in an average practice would require nearly three full - time primary care providers , practices need to reorient to a team approach in which physician assistants and/or nurse practitioners do most first - contact care , and physicians lead the care team and manage complex patients.12 pcmh demonstration projects have found expansion of multidisciplinary allied - health roles indispensable for a sustainable pcmh transition.13 this shift from physician - centered to a team approach may be the greatest personal challenge a physician faces in the pcmh transition.14 accountable care organizations can be considered integrated  medical villages  for the pcmh , coordinating evidence - based and cost - effective specialty and inpatient services with primary care.8,15 proactiveness , quality , and continuity of primary care for copd , as for other  ambulatory care - sensitive  chronic diseases , are crucial in reducing inpatient utilization.16 thus , copd care stands to benefit from the pcmh - accountable care organization approach . this review will present core pcmh concepts and discuss multidisciplinary team - based pcmh care strategies for copd . the american academy of family practice model of the pcmh is shown in figure 2 . pcmh principles were jointly developed by the american academy of family practice , american college of physicians , american academy of pediatrics , and american osteopathic association,10 and their contents are summarized with copd examples in table 1 . elements scored in the 2011 standards and guidelines for physician practice connections ( ppc)-pcmh recognition evaluations are shown in table 2.17 although ppc - pcmh , like the joint principles , defines a pcmh as physician - led , the pcmh resource organization , transformed , also recognizes pcmh practices led by physician assistants or nurse practitioners . pcmh care is labor - intensive behind the scenes as well as in patient visits and should be compensated accordingly . salary alone does not reward productivity , pure capitation encourages underuse , and pay for performance may shortchange unmetricated care . the american college of physicians18 therefore advocates blended payment that retains visit - based fee - for - service payments and adds prospective , bundled payments for the structural overhead of pcmh practices and for care - coordinating  desktop medicine activities.13 the final component is pay for performance , thus rewarding quality and efficiency goals . group health cooperative of puget sound conducted a 12-month quasi - experimental study comparing a designated pcmh practice with usual care clinics.13 prior to the study , electronic health records and same - day scheduling had been adopted systemwide . the pcmh demonstration clinic reduced clinicians case loads from about 2300 to 1800 patients , increased standard visits from 20 to 30 minutes , provided protected  desktop medicine  time , and altered the staff mix , raising physician assistant staffing levels by 44% , registered nurses by 17% , medical assistants and licensed practical nurses by 18% , and clinical pharmacists by 72%.13 at the end of 12 months , pcmh patients had 29% fewer emergency room / urgent care visits and 11% fewer hospitalizations for ambulatory care sensitive conditions ( including copd ) than usual care patients . overall costs were unchanged between the pcmh and usual care , staff burnout levels were significantly reduced , and quality indicators improved significantly more in the pcmh than in usual care.13 the group health experience exemplifies the importance of multidisciplinary contributions to pcmh success . physician assistants and nurse practitioners play important roles in pcmh transformation of practices and development of team care workflows for copd management . they can help change care culture from reactive to proactive , combat therapeutic pessimism , and design and implement copd care processes . physician assistants and nurse practitioners at the first - line primary care interface can combat patients denial of copd , encourage smoking cessation , institute maintenance treatment , and enable self - management . pcmh team members collaborating with patients can develop concordant care plans , making it easier for the patient to persevere with a smoke - free , active lifestyle and to remain on appropriate medication . chronic care for copd should strive to reduce the risk of exacerbations and delay their onset to reduce health care burden and improve health - related quality of life . the elements of primary care copd management include smoking cessation , immunizations , physical activity , pulmonary rehabilitation ( if dyspnea and functional disability are present ) , acute care of exacerbations arising , and maintenance pharmacotherapy to reduce exacerbations.1 smoking cessation , especially before the age of 4045 years , slows loss of lung function in copd to a rate usual for age.19 evidence - based smoking cessation assistance should be offered to patients choosing to quit.1,20 major copd guidelines recommend that maintenance treatment with long - acting inhaled anticholinergic or -adrenergic agents begin no later than moderate copd.1 maintenance treatment of copd may reduce severity of symptoms , reduce exacerbations , maintain activity , and improve health - related quality of life . tiotropium is approved by the us food and drug administration ( fda ) for maintenance treatment of bronchospasm associated with copd and to reduce exacerbations in copd patients ; salmeterol / fluticasone is also approved by the fda for maintenance treatment of airway obstruction in copd and to reduce exacerbations in copd patients with a history of exacerbations . budesonide / formoterol is approved by the fda for maintenance treatment of airway obstruction in copd but does not have an approved indication to reduce exacerbations . oral roflumilast received fda approval on march 1 , 2011 to reduce the risk of exacerbations of copd in patients with severe copd associated with chronic bronchitis and a history of exacerbations ( http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm244989.htm ; http://www.frx.com/news/pressrelease.aspx?id=1534051 ) . the global initiative for chronic obstructive lung disease ( gold ) guidelines of 2010 state that roflumilast may be combined with long - acting bronchodilators.1 maintenance therapies that have been shown to improve exercise parameters in patients with copd include tiotropium,21 salmeterol / fluticasone,22 combined tiotropium and salmeterol / fluticasone,23 combined tiotropium and formoterol,24 budesonide / formoterol,25 salmeterol alone,26 or formoterol alone.27 improving patients capacity for physical activity may enhance both pulmonary rehabilitation and valued life activities . care team members can connect copd patients with pulmonary rehabilitation and encourage routine physical activity , forestalling progressive deconditioning and worsening dyspnea.28 pcmh team members , including physician assistants , nurse practitioners , registered respiratory therapists , and/or designated and specially trained health coaches29 ( who may be nurses , medical assistants , or health educators ) , can teach and empower patients to self - manage copd between office visits . exacerbation self - management action plans ( such as the canadian thoracic society plan available online at http://www.lung.ca/pdf/1408_thor_actionplan_v3.pdf ) can help patients recognize and medicate exacerbations promptly and discern when to visit the primary care clinic or emergency room . provision of one education session , an exacerbation action plan , and a monthly telephone follow - up to us veterans with severe copd reduced copd - related hospitalizations / emergency room visits by 41%.30 pcmh methods provide multiple ways to improve copd care ( table 2 ) , where  practice as usual  has encountered challenges . continuous healing relationships for whole - person care can change episodic , reactive , and emergent copd care into planned ongoing proactive management . in current practice , copd care is often driven by exacerbation emergencies,31 with acute non - respiratory problems and multiple comorbidities taking primary care physician visit time away from copd concerns.11 scheduled well - care visits ( eg , every four months ) devoted to copd maintenance are a potential pcmh solution.32 some practices that conduct well - care copd visits find that patients spontaneously evolve into an informal peer support group . access to care and information can reduce copd - related emergency room use and help patients and families cope . prompt primary care of exacerbations improves outcomes , yet is difficult to achieve in current practice . direct emergency room visits for exacerbations are sometimes the initial presentation of undiagnosed and unaware copd patients.31,33 emergency room visits may result from after - hours acute events but also from patients difficulty in scheduling prompt primary care physician visits . advanced access to same - day primary care in copd chronic care programs reduces inpatient and emergency room utilization.34 group visits , which is another pcmh emphasis , allow interactive and efficient copd maintenance and patient education . nurse practitioners or physician assistants can effectively conduct group visits,35 and registered respiratory therapists can teach inhaler technique for any stage of copd and proper long - term oxygen use for hypoxemic severe copd . diabetes care has a well developed group visit methodology;36 but copd group visit models need further research . practice - based services and care management in the pcmh can integrate copd diagnosis and treatment resources . in current practice , copd diagnosis is often recorded without performing spirometry,37 maintenance treatment is underused , and adherence and persistence are insufficiently monitored.38 more newly diagnosed copd patients received primary care physician practice - based spirometry in the group health cooperative pcmh demonstration clinic than in usual care clinics.13 practice - based spirometry also may help reduce tobacco use and copd progression ; smokers who learn that they have spirometric airway obstruction are more likely to quit.39 chronic disease patient registries help a practice to improve the health of its copd patient population.40 healthcare effectiveness data and information set indicators applicable to copd care may be appropriate for within - practice tracking as well as public reporting . additional registry contents may include exacerbation rates , primary care physician follow - up after exacerbations , prescription refill rates , activity levels , employment / retirement status , and household members . if primary care providers remain unaware when their own patients are hospitalized for exacerbations , maintenance treatment may not be restarted at discharge,41 heightening the risk of recurrent exacerbations.42,43 in addition , lung function test results or pulmonologists reports may not promptly reach all primary care team members . a recent evaluation showed that group health cooperative pcmh patients were 1.89 times more likely than usual care patients to receive a call or secure email from a primary care physician within three days of hospital or emergency room discharge.13 practice - based care teams can consciously assign copd management tasks ( smoking cessation support , inhaler technique instruction , and adherence monitoring ) to specific members of the care team so that nothing needful is omitted . in a successful pcmh workflow , the division of tasks depends on individual skill sets rather than on rigid job descriptions , and every team member works at his or her highest licensed level of care . quality and safety systems , including meaningful electronic health records use and evidence - based decision support , are central to the pcmh . in current practice , guidelines are often not followed,2 and patients on maintenance treatment may be insufficiently followed up regarding adherence.38 guideline - based copd care1 includes diagnostic postbronchodilator spirometry , short - acting bronchodilators , maintenance treatment , and pulmonary rehabilitation beginning at moderate copd , and influenza and pneumonia vaccinations . electronic reminders help clinicians implement guidelines , and electronic prescribing can track patient medication use , adherence , and potential drug interactions . electronic health records , electronic prescribing , and guideline reminders are required for tiers 2 and 3 of ppc - pcmh certification . publicly reportable healthcare effectiveness data and information set indicators relevant to copd are shown in table 3 . practice management patterns in the pcmh emphasize planned , coordinated , and reflective chronic care , in contrast with current practice focusing on acute care episodes and payment for procedures.8 in a fee - for - service system , lack of payment for care coordination and registry - related tasks is a disincentive to expend energy on them.18 pcmh payment structures should reflect the value of pcmh care planning and management ( table 2 ) . the accountable care organization approach includes specialty , inpatient , and emergency room services in an integrated and electronically interoperable patient - centered medical village , sharing in the medicare savings it generates by coordinating care rather than driving supply - sensitive utilization.8,15,44 optimizing payment models for pcmh care patterns provides an economically viable and sustainable practice . the pcmh model has the potential to improve outcomes in chronic diseases , such as copd , by shifting the primary care focus from acute rescue to proactive maintenance and by shifting practice culture from maximizing reimbursable specialty procedures to maintaining coordinated , reflective , and accountable chronic disease care . pcmh - based multidisciplinary redesign of the copd care workflow offers new approaches to primary care and patient education that will contribute critically to improving patient outcomes and controlling costs in a sustainable health care system .
chronic obstructive pulmonary disease ( copd ) is a progressive and debilitating but preventable and treatable disease characterized by cough , phlegm , dyspnea , and fixed or incompletely reversible airway obstruction . 
 most patients with copd rely on primary care practices for copd management . 
 unfortunately , only about 55% of us outpatients with copd receive all guideline - recommended care . 
 proactive and consistent primary care for copd , as for many other chronic diseases , can reduce hospitalizations . 
 optimal chronic disease management requires focusing on maintenance rather than merely acute rescue . 
 the patient - centered medical home ( pcmh ) , which implements the chronic care model , is a promising framework for primary care transformation . 
 this review presents core pcmh concepts and proposes multidisciplinary team - based pcmh care strategies for copd .