COPD Re-admission Prevention Program
- Need: Organized effort targeting COPD patients’ medical needs in order to prevent hospital readmission in Zanesville, Ohio.
- Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
- Results: Improved readmission rates and overall improved acute and chronic care for the area’s COPD patients.
In 2013-14, with an eye on the Centers for Medicare and Medicaid Services’ Hospital Readmissions Reduction Program expansion to include chronic obstructive pulmonary disease (COPD), Genesis HealthCare System began a readmission prevention program. The program concept had roots in the organization’s administrative suite in Zanesville, Ohio. The current program design includes a regular reassessment in order to continually advance COPD patient care.
Using several evidence-based approaches, the program operates in a systems continuum. The program starts with inpatient nursing and respiratory therapy staff, with further care coordination formally transferred to two program navigators. Both navigators are Registered Nurses with critical care experience and both are also certified Tobacco Treatment Specialists (TTS).
This care coordination focus also intersects with patients’ family and friends, providers, pharmacists, durable medical equipment providers, social workers and appropriate community agencies for any specific assistance.
No start-up funding was utilized since Genesis administration recognized that sustainable financial and patient-care benefits would likely emerge once the program was operational.
In 2017, Genesis HealthCare System achieved the U.S. News & World Report's highest rating possible for both COPD and Heart Failure.
The program’s overall approach addresses known areas of care coordination breakdown ("patient handoffs, follow-up care, ongoing care for those with chronic conditions, and care when something goes wrong").
At time of index admission:
- Case management patient screening for potentially high readmission risks
- Initial problem-solving for the identified risks
- Disease and self-management education provided by nurses and respiratory therapists
- Using a specific electronic record discharge order set, the high risk patient’s information is immediately sent to the COPD nurse navigators
- Optional patient choice: use of bedside discharge medication delivery to eliminate the chance of missed medication doses
- COPD nurse navigators engage with patients and further evaluate risks using the Modified LACE Index tool
- The outpatient hospital-associated COPD clinic nurse practitioner is available for patients unable to see their primary providers after discharge or for acute clinical care needs
- An on-site pulmonologist is also available as needed
Immediately post discharge, nurse navigators call patients within 48-72 hours. They assist the patient in obtaining a follow-up appointment within 5-7 days of discharge with either the patient’s primary care provider or the COPD Clinic’s nurse practitioner. An additional goal is a follow-up appointment during the 14-21 day post-discharge interval.
The nurse navigators monitor patients’ progress with follow-up phone calls as needed, providing timely disease and self-management education. They continue to trouble-shoot unmet related social determinants of health, for example, the ability to purchase and correctly use medications.
When the acute illness has stabilized, pulmonary function testing is encouraged. If patient is eligible, pulmonary rehabilitation, another evidence-based intervention, is also encouraged.
In 2016, the program’s success was highlighted by the Advisory Board Company as a Crimson Program demonstrating chronic disease management efforts that impacted hospital admissions and care utilization. In its initial six months, readmission rates decreased by 34%, saving its organization over $500,000. Further data regarding Genesis’s readmission rates can be reviewed using Data.Medicare.gov.
Ongoing successes make the program sustainable from an administrative perspective. Additionally, the organization has been contacted by several of the state’s academic medical centers and other hospitals to further understand program elements for possible replication.
As the program continues and engages more patients, staff are seeing an increased number of COPD patients referred by those patients who experience better health and improved quality of life due to program participation.
- Reluctant patients
- Transportation difficulties
Joy Stashonsky RN, BSN, TTS, COPD Nurse Navigator
Genesis HealthCare System
Chronic respiratory conditions
Service delivery models
November 29, 2017
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