Project COPD Connect Innovates to Better Serve Patients

elderly man sitting in a chair and looking at an iPad

John Berg uses an iPad to talk to a nurse at MaineHealth Care at Home.

In early 2021, MaineHealth Care at Home (in partnership with the Coastal Healthcare Alliance and Healthy Living for ME) were awarded nearly $800,000 for a four-year project, Project COPD Connect.

Serving patients in Knox and Waldo County, Project COPD Connect integrates home health services, telehealth, palliative care and existing community supports with a COPD nurse navigator. The nurse navigator uses evidence-based chronic disease navigation practices to guide patients through the disease process and connect them with their health care team across the community to support improved outcomes.

Kristin O’Mara, RN, has taken on the role of COPD nurse navigator in addition to her time spent as a telehealth RN. For Kristin, the opportunity to work directly in the field with patients was an attractive option to add to her role within the agency.

“My biggest goal is to help patients improve their quality of life and have a better understanding about COPD and their medications.  By building relationships with patients, their families, and providers I hope to help patients have improved control of COPD, reduced ER visits and hospitalizations.”

— Kristin O’Mara, RN

Rural Health Care Services Outreach Program

A community-based grant program aimed towards promoting rural health care services by enhancing health care delivery to rural underserved populations in the local community or region.

Learn More About the Outreach Program

To date, patients enrolled in the program have received:

Navigation “touchpoints”

Telehealth encounters

Home health visits

Encounters with the patient’s primary care provider

The wrap-around nature of the program offers patients the ability to lean on the COPD nurse navigator and other members of their care team as they deal with the mental, physical and emotional challenges of COPD.

Over time, the project aims to develop a base of evidence in support of the integration of nurse navigation services for patients with advanced chronic disease.