There are a number of strategic approaches health systems take to strengthen COPD care inside and outside the hospital to prevent readmissions. Arguably, these approaches work best when taken in combination.
For example, Cone Health in Greensboro, North Carolina invested in a system-wide COPD readmissions reduction program. Their program included a gap analysis to identify unmet areas of need, integrated COPD order sets in the EHR to ensure adherence to evidence-based guidelines, standardized care processes to promote use of pulmonary rehab and multidisciplinary COPD care, automated phone-based post-discharge support, and dedicated clinical decision support in the ED. After just 18 months, Cone Health avoided nearly 2,000 COPD admissions, resulting in $13.4 million in cost savings.
Here are four major components of Cone Health's program that should extend across any COPD strategy.
1. Take a multi-pronged approach to uncover patient needs and utilization drivers
Key factors driving COPD readmissions vary from hospital to hospital, even within the same system. Analyze high-level data sources, patient medical records, and patient feedback to get a full picture of patient needs and utilization drivers.
Don't overlook the role that psychosocial factors play in exacerbating COPD symptoms: The leading cause of COPD is smoking, which carries with it a stigma that may prevent patients from seeking care or subtly influence how providers treat patients.
2. Standardize care protocols and role definition to raise quality of inpatient care
Following the root cause analysis, implement targeted strategies to fill identified gaps in care, starting within the four walls of the hospital. These efforts include standardizing care protocols (e.g., following the Global Initiative for Chronic Obstructive Lung Disease guidelines for COPD management) and multidisciplinary care team roles (e.g., differentiating patient ownership responsibilities across respiratory therapists, nurse navigators, and social workers). Don't forget to use social workers on the team to address psychosocial barriers to health, and to have case managers deliver COPD-specific education throughout a patient's stay.
3. Ensure continuity of post-acute care through effective post-discharge follow-up and care coordination
Appropriate post-discharge follow-up is critical to reducing hospital readmissions, since symptom exacerbation is the leading cause of readmission among COPD patients. Whether sharing education materials with local skilled nursing facilities (SNFs) or using post-discharge clinics to bridge the gap to primary care, focus on providing timely and thorough post-discharge care. Then target coordination efforts at SNFs and home health agencies.
4. Prevent admission from within the hospital by educating ED staff on how to handle acute COPD needs
While the goal should be to keep patients away from the hospital altogether, it's inevitable that some patients will present in the ED due to poor condition management. Provide ED physicians with other options for patient management beyond discharging patients with limited support or admitting to the hospital. Cone Health added two new COPD pathways: 1) Provide patients with telehealth and short-term transitional support when discharged; and 2) Admit patients with unclear status to an observation unit to stabilize and get proper diagnosis.
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