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Diminish COPD Readmissions by Reducing Barriers to Health at Home

By Mandy Roth  
   July 23, 2018

Community hospital population health initiative reveals many patients don't use equipment properly at home.

With COPD comprising the second largest reason for 30-day readmissions at Johnston Health in Smithfield, N.C., the 199-bed community hospital system launched a population health initiative that has united forces inside and outside hospital walls to address this chronic and costly disease. The key focus: What barriers exist to keeping patients well at home?

The comprehensive approach involves multiple initiatives, but the "secret sauce," is a post-discharge, in-home patient visit, says Peter Charvat, MD, vice president and chief medical officer of Johnston Health, an affiliate of UNC Health Care, Chapel Hill, N.C. The on-site appointment is conducted by a paramedic who brings a respiratory therapist (RT) into the encounter via an electronic tablet. The duo explores every aspect of home care. Among their findings:

1. Visits Reveal Improper Use of Home Equipment

The program has homed in on a key problem: even patients who have had COPD for years often are not properly using their inhalers, or oxygen and nebulizing equipment. It's not unheard of to find equipment stowed in a closet, unused.

2. Medication and Transportation Create Challenges

Other issues include improper use of medication, plus lack of transportation to numerous post-discharge appointments, which might include primary care providers, pulmonary rehabilitation and smoking cessation classes offered by the county.

3. Complexity Creates Chaos

COPD patients have to deal with multiple, disconnected entities and processes, such as complex discharge instructions, durable medical equipment companies, home health services, and possibly skilled nursing facilities.

Multidisciplinary Approach

Dr. Charvat, a member of HealthLeaders' Population Health Exchange, brought all these outside entities into the process. The group also included hospitalists and respiratory therapists, as well as representatives from nursing, the emergency department, outpatient rehabilitation and administration. They opened lines of communication and devised a plan for better approach to COPD care.

One unique element: leveraging a partnership with the county EMS system to use their paramedics to conduct home visits. Cost is shared by the health system and the county.

4-Step Program

The COPD program included four elements:

  1. Multidisciplinary team approach
  2. Standardization of practice and a reduction of inappropriate provider variation
  3. Patient education
  4. Post-discharge patient contact

Post-discharge patient contact included:

  • The on-site paramedic/RT tele-visit during week one to review proper use of equipment and medication
  • Phone calls during weeks two through four, when possible
  • Pulmonary rehabilitation
  • Smoking cessation, if applicable

Long-Term Perspective

In the four months after launching the program, readmissions dropped about 35 percent, then rose, and, in recent months they have fallen below the 17% threshold the team wanted to surpass. Eleven months into the program, overall readmission rates are about even with the previous period, but most patients are being readmitted for reasons other than COPD, Dr. Charvat says.

"I've been very clear to our people," says Dr. Charvat. "this is a thousand-day journey. In our first year, we developed the infrastructure, and we started doing things that we had never done before." Year two will determine what program elements are successful and year three will result in further development.

"We set out to better manage patients and we have done that," Dr. Charvat says. "I really believe we're managing the disease better overall, because in the end, our efforts are really focused on COPD."

Additional Benefits

The Johnston Health COPD program also produced additional benefits:

  • Using paramedics and RTs eliminates the need to navigate around physicians' schedules and help reduce their load
  • Patients without technology, or those who are technology averse, can still participate in the telehealth aspect of the program because paramedics bring the electronic tablet with them and set up the connection with the respiratory therapist. In addition, the service does not require a home Internet connection. 
  • The program helped standardize care delivered between inpatient and outpatient RT departments
  • The process helped build a connection between the hospital, durable medical equipment providers and skilled nursing facilities

Cost and Impact of COPD

  • "COPD is the third leading cause of death in the United States. More than 11 million people have been diagnosed with COPD, but millions more may have the disease without even knowing it," according to the American Lung Association. "COPD causes serious long-term disability and early death. At this time there is no cure, and the number of people dying from COPD is growing."
  • A study published June 17, 2013, in ClinicoEconomics and Outcomes Research online quantified the financial impact: "In 2010, the cost of COPD in the USA was projected to be approximately US$50 billion, which includes $20 billion in indirect costs and $30 billion in direct health care expenditures."

Mandy Roth is the innovations editor at HealthLeaders.

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