By Jeanie Davis
Patients are not one size fits all when discharged with COPD. “They’re complicated, not one defined entity,” says Carolyn M. D’Ambrosio, MD, MSc, director of Pulmonary and Critical Care fellowship at Brigham and Women’s Hospital, and associate professor of medicine at Harvard Medical School.
“These are patients who typically get their disease from smoking tobacco, which increases risk for many other medical conditions, specifically coronary artery disease,” she explains.
Smoking affects every COPD patient differently, D’Ambrosio says. “Some patients have significant destruction of lung tissue characterized as emphysema with COPD. Other patients have minor airway obstruction with only minor destruction of lung tissue, so it’s hard to put them in the same category.”
However, “in readmission rates they’re all lumped together,” she adds. “That’s the biggest problem with proper discharge planning for COPD: It’s not one size fits all.”
Her team’s assessment is comprehensive. “Breathing: Is it back close to baseline, when it was good as can be? Oxygen levels: Does the patient need oxygen all the time, when they’re sleeping, when they exert themselves? We make sure if they do need oxygen, they can go home with it on, and tanks delivered to their home.”
It also is critical to ensure patients use correct medications, inhalers, or nebulizers. Do they know the proper inhaler technique? Are they taking the correct medication for their COPD? Do they understand their inhalers?
One of biggest problems, D’Ambrosio says, is patients forget which is their everyday inhaler, and which is their rescue inhaler. “It can be very complicated for them,” she explains. “Very often, we label the inhaler. We go over using it, and ask the patient to repeat it back, to make sure they understand it.”
Patients mostly are older people, although some are in their 30s and 40s. “Those in the older age range might be living alone without someone helping them, which is a bit of a challenge,” she explains. “When they’re short of breath, and the inhaler is across the room, that’s an effort to get it.”
Best-case scenario is when the discharge planner, nurse, and pulmonologist can help the patient strategize, she advises. “We can figure out where the best place for their inhaler is — in their pocket, or on the bedside table. Simple things like that, so they’re not struggling to find their inhaler.”
Patients must receive pneumonia and flu vaccines. “Also, make sure everything else is tuned up,” she adds. “If they have other conditions, like heart disease and heart failure, make sure they’re treated before leaving the hospital. You want their condition to be optimal, or they will be coming back.”
Home assessments are valuable. If necessary, some patients experiencing more difficulty can be sent to a rehabilitation hospital short-term. Short-term visiting nurses also can be arranged to ensure inhalers are labeled, and everything is set.
Some patients benefit from outpatient rehabilitation two to three times a week for up to four weeks, until they are stabilized.
Unfortunately, not all outcome are positive. “Sadly, the data don’t support these improvements helping readmission rates, largely because patients are not one-size-fits-all,” D’Ambrosio says. “We know that improving heart failure has reduced readmission rates. However, for patients with COPD, something as simple as the common cold can get them readmitted because their COPD is severe.”
Her team has identified specific interventions that can lead to short-term improvements. But the patient may be unable, or unwilling, to make necessary changes. “As disease progresses, some are still smoking and still injuring their lungs. We offer smoke cessation programs, but nicotine is tough to kick. Many people who smoke live with people who smoke, so they’re being exposed to secondhand smoke.”
Stabilizing the patient before they leave is the best approach, D’Ambrosio says. “We make sure they have the services they need, like oxygen, outpatient, or inpatient rehabilitation. If all has been planned carefully and arranged appropriately, then we’ve provided the best care we can. They’re on the best medicine, and they’re stabilized.”
There must be close follow-up with the pulmonary doctor, she adds. “They need to be seen in the office after two to three weeks to make sure they’re settled on a good path.”
Lean Analysis Reduces Readmissions
The “Five Whys” of the Lean healthcare model are key to reducing readmissions, says Lesli McGee, MSIHC, corporate vice president of care coordination and operational improvement at McLeod Health in Florence, SC.
Lean is a healthcare management system that seeks to continuously improve and eliminate waste in patient care. McLeod Health uses the tools and techniques of Lean improvement methodology to constantly re-evaluate their processes, and find ways to make outcomes more successful, McGee explains. “This equates to constantly improving value for the patient.”
To apply the Five Whys to the COPD population, which readmits at a high rate, McLeod Health implemented a readmission assessment that incorporates finding the root cause of each patient’s barriers to health. In assessing a readmitted patient, the case manager asks “why” to each answer, digging deeper.
“We keep asking questions until we get to the true root cause, which may be very different than their first answer,” explains McGee. “Unless we get to that root cause and put a plan in place to correct it, that patient is going to return to the hospital.”
The questions run like a decision tree. Follow-up questions asking a deeper “why” are based on the answers. “In the instance of medication noncompliance, they ask if the patient took their medications. If the patient answers ‘No,’ rather than label them as noncompliant and stopping there, they use the Five Whys,” McGee explains. “They may discover that the reason the patient didn’t take the medication was that they didn’t have their prescriptions filled. They ask ‘why’ again. It may be that the patient can’t afford the medication, or they didn’t have a ride to the pharmacy. Both issues are easily corrected by a resourceful case manager, but they have to know about the problem.”
If the answer to the first question is that the patient filled the medications, then the decision tree takes the case manager down another path, learning the patient’s health literacy level, understanding assistance the patient receives at home, and even where the medications are kept at home.
“There are so many variables with each patient, that knowing what to fix is a huge key to reducing readmissions. Patients don’t willfully and intentionally decide to quit taking medications; it’s rarely ever that,” McGee says.
She adds: “In questioning the patient and family, it’s important to be gentle, helpful — not blaming the patient. You’ve got to keep digging, which may feel invasive at times. We’re not finding fault; we’re finding solutions to the problem. That must be the tone.”
It is important to ask questions regarding caregiving, diet, and other factors involved in the patient’s home care. Transportation to doctor appointments often is a barrier.
“Case managers might schedule all the needed follow-up appointments, but if the patient can’t get a ride on two different days, they won’t go to two different appointments,” says McGee. “We have to think about the patient’s needs, and work to meet their needs by scheduling both appointments on the same day.”
Time for Palliative Care?
McGee finds that some patients who have used all medical interventions and are readmitted often are candidates for palliative care. “If the patient has a history of not engaging in their treatment, or has exhausted all their options, it may be time for a palliative care consult, so we can help them find the best quality of life for the remainder of their life,” she explains.
Case managers often run into resistance when suggesting this move, McGee admits. “We find that physicians are not familiar with palliative care, and families struggle with making that decision. We do what we can without destroying trust, and try to support them in their decision-making.”