Prevention & Proactive Intervention is Key to Reducing COPD Readmissions
By Brian Tiep, MD; Brian Carlin, MD
To say readmissions are costly for hospitals is an understatement. More than half of hospitals nationwide will be paying $528 million over the next year in Medicare penalties. While readmissions have decreased an average of 8% nationally since the penalties were rolled out in 2010, it’s still not enough. Patients are either not being given clear information on how to manage their conditions outside of the hospital, or they don’t follow through on the information they’re given.
This is especially true for the estimated 24 million Americans living with Chronic Obstructive Pulmonary Disease (COPD). Without proper prevention and proactive intervention, the risk of being hospitalized -- maybe ending up in the ICU or on a ventilator -- is greater. Studies have shown 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. If hospitals want to further reduce readmissions and lower penalty costs, patients must be trained and supported in the lifelong management of their illness, not simply through the acute aspects of the disease.
Education, Training & Reinforcement = Prevention
Most hospitalizations for exacerbations are avoidable. While many healthcare institutions have programs in place 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 providers.
As pulmonologists who’ve been treating COPD patients for decades, we’ve seen firsthand how a continuum of care approach can reduce or eliminate the need for rehospitalizations caused by exacerbations. For example, over the course of a 15-year clinical trial (see attached study .pdf) through the Respiratory Disease Management Institute in Upland, CA, patients with COPD were educated, trained and retrained on pulmonary rehabilitation skills during monthly doctor’s 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 the patient and reinforced by a healthcare provider. Patients in the trial were also provided with an exacerbation Rapid Action Plan, so if they experienced a “flare-up”, they knew what steps to take to manage it effectively and efficiently.
The result? Patients who followed a continuous care model did very well despite having a chronic disease. This continuous care model of education, training and reinforcement over the life of a patient was shown to limit COPD exacerbation admissions to just 4%, versus a 27% hospitalization rate for referent groups.
In a separate trial, 23 hospitals in the Western Pennsylvania area provided a similar educational outpatient approach to COPD patients who required supplemental oxygen. Over a 26 month period, these patients were provided with three face-to-face visits with a respiratory therapist during the 30 days following their discharge. They were taught behavioral modification and basic management skills. Some patients were additionally given weekly phone calls with a care coordinator. This project was also successful at reducing readmissions -- they went from an average of 25% down to 5%.
Both studies illustrate that most hospitalizations from “flare-ups” are, in fact, avoidable if COPD patients are seamlessly transitioned from the acute through the chronic phases of the disease.
Patient Involvement Is Vital
Most current models of out-patient and at-home care rely heavily on medications and devices to help COPD patients manage this disease. However, they miss a vital part -- the individual patient’s lifestyle and level of commitment. While cross continuum education, training and reinforcement can go a long way in helping to reduce and / or prevent COPD readmissions from happening, patients must also be actively involved in the monitoring and management of their disease. This is truly the definition 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 don’t exercise. They may have started smoking again. All of these factors could cause exacerbations, which could lead to hospitalizations.
That’s why individualizing care for each patient is imperative. While 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 necessary tools to proactively participate in their own care:
-Daily Rituals - A Checklist of Responsibilities & Daily Activities
Managing COPD takes consistent behaviors on the part of the patient. It’s not enough to provide educational materials to patients when they’re in the hospital for an acute episode, as many don’t remember what they were taught when they return home. They should also be given a checklist of responsibilities and daily activities to follow after they’ve been discharged, which we call Daily Rituals. This list can be specifically tailored to the individual patient’s cognitive, family and financial considerations and needs.
Additionally, 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 by multiple doctors are reconciled and the patient knows proper dosage and frequency. They can also see, in real time, if any steps are being missed and can adjust accordingly.
The Daily Rituals can also include daily exercises which can help with reconditioning. While exercise itself can’t reverse COPD, it has long been an important part of disease management, and one that can go far in early recognition of “flare-ups”.
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. (An independent study tested the accuracy of three popular brands of pulse oximeters by simulating real life conditions of COPD patients. Its findings can be found here.)
In addition to equipping patients with the right knowledge, there’s also 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 a patient waits to take medication or seeks treatment for a “flare-up”, the more destructive it can be. In essence, “time is tissue.” That’s why early intervention is paramount in successfully avoiding relapses. If exacerbations are caught early and treated quickly, studies have shown that hospitalizations may be avoided.
Patients should be taught how to rapidly recognize the warning signs of an exacerbation or a relapse, as well as given a clear process for a rapid response when it does happen. For example, if they start to notice that they’re experiencing more shortness of breath for the same level of exertion and / or they have a change in sputum, that’s when their “rapid action plan” kicks in. This plan spells out what the patient should do, what medications to take and who to call. By rapidly taking these proactive steps, patients can learn to live with their disease 24 hours a day 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 connect the “disconnects”, 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. All of these issues are addressed in a new COPD STEP plan on which we collaborated together along with other medical professionals. Details can be found here.
Republished from the Healthcare Financial Management Association (HFMA) February 2017 Newsletter