Hospitals that provide COPD patients with comprehensive education and support can prevent unnecessary hospitalizations.
To say readmissions are costly for hospitals is an understatement. More than half of hospitals nationwide will pay $528 million during the next year in Medicare penalties, according to an analysis from Kaiser Health News (Rau, J., “Medicare’s Readmission Penalties Hit New High,” Kaiser Health News, Aug. 2, 2016). Although readmissions have decreased an average of 8 percent nationally since the penalties were rolled out in 2010, it is still not enough (Conway, P., Gronniger, T., The CMS Blog, Sept. 13, 2016). Patients are either not receiving clear information on how to manage their conditions they do not follow through on the information they receive.
This is especially true for the estimated 30 million Americans living with chronic obstructive pulmonary disease (COPD). Without proactive intervention, the risk of being hospitalized—perhaps even ending up in the intensive care unit (ICU) or on a ventilator—is greater for these patients.
Studies show that COPD exacerbations not only make up more than half of the cost of COPD services, they also account for the bulk of hospital admissions (Qureshi, H., Sharafkhaneh, A., and Hanania, N.A., “Chronic Obstructive Pulmonary Disease Exacerbations: Latest Evidence and Clinical Implications,” Therapeutic Advances in Chronic Disease, September 2014; Jencks, S.F., Williams, M.V., and Coleman, E.A., “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” The New England Journal of Medicine, April 2, 2009). If hospitals want to further reduce readmissions and lower potential penalties, they should train patients lifelong illness management.
Prevention through Patient Support
Most hospitalizations for COPD exacerbations are avoidable. Although many healthcare organizations have programs in to treat the acute aspects of COPD, their post-discharge programs supporting the chronic aspects often fall short. For example, home visits have been shown to reduce the risk of readmission after an acute exacerbation; unfortunately, those visits are not typically provided by hospitals or reimbursed by insurance providers (Puhan, M.A., Scharplatz, M., Troosters, T., et al., “Respiratory Rehabilitation after Acute Exacerbation of COPD May Reduce Risk for Readmission and Mortality—A Systematic Review,” Respiratory Research, 2005).
A continuum of care approach can reduce or eliminate the need for rehospitalizations caused by exacerbations (Tiep, B, MD, Carlin, B., MD, et al., “COPD Patient 30-Day Hospital Readmission Reduction Program,” Nonin Medical, 2016). For example, during the course of a 15-year clinical trial through the Respiratory Disease Management Institute in Upland, Calif., patients with COPD were educated, trained, and retrained on pulmonary rehabilitation skills during monthly physician office visits. These skills, which included everything from how to properly use an inhaler to how to recognize the signs of an exacerbation, were consistently practiced by patients and reinforced by healthcare providers. Patients in the trial also received exacerbation rapid action plans, so if they experienced flare-ups, they knew how to manage them effectively and efficiently.
The result? Patients who followed a continuous care model did well despite having a chronic disease. This continuous care model of education, training, and reinforcement during the life of a patient was shown to limit COPD exacerbation admissions to just 4 percent, versus a 27 percent hospitalization rate for referent groups (Tiep, B., Barnett, M., and Carter, R., “ Lifetime Management of COPD via a Clinical Guidance System: Update on the 12th Year of a Continuous Care Model,” American Journal of Respiratory and Critical Care Medicine, 2014).
In a separate trial, 23 hospitals in the Western Pennsylvania area provided a similar outpatient approach to educating COPD patients who required supplemental oxygen. During a 26-month period, these patients participated in three face-to-face visits with respiratory therapists during the 30 days following their discharges. They learned behavioral modification and basic management skills. Some patients also participated in weekly phone calls with care coordinators. This project also was successful at reducing readmissions; they went from an average of 25 percent down to 5 percent (Carlin, B., Wiles, K., and Easley D., “Transition of Care and Rehospitalization Rates for Patients Who Require Home Oxygen Therapy Following Hospitalization,” European Respiratory Journal, 2012).
Both studies show that most hospitalizations from flare-ups are avoidable if COPD patients are seamlessly transitioned from the acute to the chronic disease phases.
Patient Involvement Is Vital
Most current models of outpatient and at-home care rely heavily on medications and devices to help COPD patients manage this disease. However, they miss two vital elements: the individual patient’s lifestyle and level of commitment. Although cross-continuum education, training, and reinforcement can go a long way in helping to reduce or prevent COPD readmissions from happening, patients also should be actively involved in the monitoring and management of their diseases. This is at the heart of patient-centered care.
Too often, key treatment steps fall through the cracks after COPD patients are discharged. For example, patients may not take their medications properly. They may not have their oxygen. Many do not exercise. They may start smoking again. All of these factors could cause exacerbations, which could lead to hospitalizations.
That is why individual care for each patient is imperative. Although the symptoms may be similar, each COPD patient’s situation is different. By incorporating the following into a patient-centered care approach, healthcare providers can equip patients with the following necessary tools to proactively participate in their own care.
Daily rituals—a checklist of responsibilities and daily activities. Managing COPD requires consistent patient behaviors. It is not enough to provide educational materials to patients when they are in the hospital for an acute episode, as many do not remember what they were taught when they return home. They also should receive a checklist of responsibilities and daily activities, which we call daily rituals, to follow after discharge. These daily rituals include using pursed-lips breathing, walking, and checking for flare-ups. This list can be tailored to the individual patient’s cognitive, family, and financial considerations and needs.
In addition, the presence of a COPD coordinator who follows the patient across the continuum of care, such as a nurse or respiratory therapist, can help ensure that medications prescribed by multiple physicians are reconciled and that the patient knows the proper dosage and frequency. A coordinator also can see, in real time, if any steps are being missed and can adjust accordingly.
The daily rituals also can include daily exercises that can help with reconditioning. Even though exercise itself cannot reverse COPD, it has long been an important part of disease management, and one that can go far in early recognition of flare-ups.
Proper equipment. Adequate oxygen equipment, airway clearance devices, metered-dose inhaler spacers, and pulse oximeters can be keys to helping patients unlock a more active lifestyle while confidently managing their disease.
In addition to equipping patients with the right knowledge, there also is a need for proper equipment and training for how to use it. Unlike other patients who take oral medications, most COPD therapies are inhaled. As such, patients need to know how to properly administer them.
Rapid action plan. Time is critical in the management of COPD, especially when it comes to exacerbations. The longer patients wait to take medications or seek treatment for flare-ups, the greater the impact on health. That is why early intervention is paramount in successfully avoiding relapses and hospitalizations.
Patients should be taught how to rapidly recognize the warning signs of exacerbations or relapses, and they should be taught how to respond rapidly when exacerbations and relapses occur. For example, if they start to notice they are experiencing more shortness of breath for the same level of exertion, or if they have a change in sputum, their rapid action plan should kick in. Such plans spell out what the patients should do, what medications they should take, and whom they should call.
By rapidly taking these proactive steps, patients can learn to live with their disease and confidently take care of themselves before the exacerbation gets out of control and they end up back in the hospital.
Connecting the “Disconnects”
Ultimately, by adopting strategies that address gaps in care, readmissions can be reduced. If we can address both the physiological and behavioral patient responses to exacerbations—as well as manage the acute and chronic aspects of the disease through a coordinated team and patient-centered care approach—we can improve outcomes, lower per capita costs, and help COPD patients live fuller and more active lives.
