Critical Path Network

Transition reduced readmission rate for COPD patients

Program includes case management in the home

By developing and following a comprehensive plan to improve care and transition to the community for patients with chronic obstructive pulmonary disease (COPD), UPMC St. Margaret Hospital has reduced the readmission rate by 16% for patients with a primary diagnosis of COPD and by 27% for patients with pneumonia and a secondary diagnosis of COPD.

The program includes a comprehensive educational component that is used by all disciplines who work with patients with COPD, a redesign of the respiratory therapist work process, a shifting of some responsibilities from nursing to respiratory therapy to improve consistency, and creating the position of community case manager — someone responsible for meeting patients when they are in the hospital, visiting them at home, and educating them on their chronic lung disease and self-management techniques.

Representatives from the hospital worked with the Pittsburgh Regional Healthcare Initiative, a nonprofit agency dedicated to improving safety and quality in health care to identify areas where the hospital could improve outcomes and reduce readmission rates.

"Those meetings determined that COPD is an area where we could improve patient outcomes. The disease is the fourth-leading cause of hospital readmissions in Western Pennsylvania, and our hospital had one of the highest readmission rates at slightly over 25%," says Isabel MacKinney-Smith, BSN, RN, CCM, COPD community case manager.

The hospital created a multidisciplinary team that included primary care physicians; pulmonologists, who were the physician champions; nursing; respiratory therapy; physical therapy; occupational therapy; nutrition; home care; and representatives from the emergency department, electronic health records, and care management and quality departments.

The team examined the processes of care from the time patients with COPD arrived at the door, either through the emergency department or through direct admissions, and throughout the entire hospital stay until discharge.

The team found that a number of patients who were readmitted had underlying pneumonia with a secondary diagnosis of COPD.

"We included both patient populations — those with a primary diagnosis of pneumonia and a secondary diagnosis of COPD and those whose primary diagnosis was an exacerbation of COPD," she says.

The team also developed evidence-based physician order sets so that when patients with COPD presented in the emergency department or as a direct admission, the admitting physician could pull up the order set and order evidence-based care from the outset of that patient's admission.

During a two-day process improvement session, the team looked at the respiratory therapy work flow process for ways to improve it and reduce waste.

Team members shadowed the clinicians who provide care for COPD patients and determined that not all clinical disciplines were providing consistent education on breathing techniques and energy conservation and that not all patients were receiving consistent instructions on how to use inhalers.

The team members who monitored the respiratory therapists noted there was a significant amount of waste in the therapists' work process. They observed that the therapists spent a lot of time walking back and forth between patient rooms and that they were writing their documentation on cards and then entering it into the electronic medical record at the end of the shift.

The team redesigned the respiratory therapy work carts to make room for a portable computer the therapists could use for real-time documentation.

Respiratory therapy took responsibility for the administration of the inhalers, previously handled by the nursing staff, so there would be more consistency on the teaching the patients receive on how to use them. Respiratory therapists also took responsibility for enhanced teaching on smoking cessation.

At the same time, the hospital added another full-time equivalent therapist to the department to accommodate the extra work load.

The team decided that all the disciplines who would be caring for the patients with COPD patients should use consistent educational materials. They researched what was available and identified a booklet that has comprehensive information about living with COPD.

"We wanted a consistent approach across all the disciplines. Now each discipline uses the booklet 'Living Well with COPD' as a basis for their teaching," MacKinney-Smith says.

The hospital created a new position, COPD community care managers, to assist patients with the transition from the hospital to home.

"We realized we had to incorporate care for these patients after they left the hospital in order to reduce readmission rates," MacKinney-Smith says.

While the patients with COPD are in the hospital, the entire clinical team educates them on why their physician has ordered each medication, how to take or use it, what to do in case of a flare-up, and how to keep their COPD under control rather than having it control their lives.

During the hospital stay, MacKinney-Smith visits patients and their family members in the room, explains the COPD home visit program, and offers them the opportunity to participate. The home visit program is strictly voluntary.

"We offer it to every COPD patient who will be discharged to home and are working to expand to assisted living and skilled nursing facilities in our area. The home program is voluntary and we give them the option of refusing it," she says.

The home visits generally last about an hour and a half and are tailored to meet the educational needs of the patients and their families.

During the visit, MacKinney-Smith completes a three-page home assessment to find out how much patients understand about their disease and their treatment plan and documents the teaching she does as well as the patients' areas of concerns. She then electronically transmits the document to the patient's primary care physician within 24 hours of the home visit.

"A lot of the information that I gather is helpful for the primary care physician. I include any issues and problems the patient is experiencing to make sure the physician is aware of it," she says.

When she visits the patients' homes, MacKinney-Smith looks for factors that could exacerbate the individual patient's condition.

"Home visits are very helpful in determining the patients' needs because when I see patients on their own turf, I can pick up on problems that wouldn't be apparent to the staff who see them in the hospital or the physician's office. Sometimes little changes can make a significant improvement in a patient's health," she says.

For instance, MacKinney-Smith always checks the patients' equipment to determine if they are cleaning and storing it properly.

"In addition to inhalers, many patients are using oxygen nebulizers or CPAP or BiPAP sleep equipment. When the equipment is first issued, the patients receive instruction on proper cleaning and maintenance, but sometimes their attention to detail falls by the way side over the years," she says.

She teaches the patients the physiology of COPD, how to avoid triggers to exacerbation, the importance of smoking cessation, and educates them about their medication.

"I tailor the teaching to each patient's particular inhaler and make sure they understand how to use them properly and when to use them," she says.

She shows patients breathing techniques that will help reduce shortness of breath, coughing techniques, energy conservation techniques, beneficial exercises and works with the patients to develop an action plan for managing their COPD.

"I help them identify how they feel when they are at baseline and what activities they can participate in when they feel well," MacKinney-Smith says.

She goes over the typical symptoms of a COPD exacerbation and teaches patients what to do when they experience each of the symptoms.After the initial home visit, she follows up by telephone weekly for at least a month.

Most of the patients already have primary care physicians. If not, MacKinney-Smith helps them find a physician to see in the clinic for follow up.

She works with all patients to make sure that they see their primary care physician within seven days of discharge.

"We're continuing to work on the best way to get these appointments set up. The goal is to try to set up the appointment before the patient leaves the hospital. Sometimes it's not possible because the appointment has to be at a time that doesn't conflict with their caregivers' work schedule. If the patients don't have an appointment by the time I visit them at home, I try to expedite the process and get them in to see their doctor as soon as possible," she says.

With the price of medications soaring, affordability of medications has become a huge issue for COPD patients, MacKinney-Smith points out.

"The maintenance medications for COPD are among the most expensive on the market. Many of these patients are elderly and have Medicare Part D benefits but are entering the donut hole early in the year and having a problem affording their medicines," she says.

If patients are having trouble paying for their medications, MacKinney-Smith helps them access patient assistance programs and works with their primary care physician to help them get the medication free or at a reduced cost.

She encourages the patients to participate in the hospital's community education classes on COPD to enhance the teaching that's done in the hospital and the home. The classes include information on exercise and energy conservation, nutrition, medication adherence, the COPD action plan, and smoking cessation. They are free and open to patients and family members as well as members of the community and serve as a support group for people with COPD.

"The program has been very well received by patients and their families. They are happy to have the tools that help them know what to do to manage their chronic lung condition," she says.

[For more information, contact:

Isabel MacKinney-Smith, BSN, RN, CCM, COPD community case manager, UPMC St. Margaret Hospital, e-mail:]