Need: Improve readmission rates for rural patients with Chronic Obstructive Pulmonary Disease (COPD).
Intervention: COPD Inpatient Navigator program implementation in a rural hospital in Oregon.
Results: With navigator assistance, COPD-associated readmission rate has decreased by almost 50%, with a continued improvement trend.
In rural America, chronic obstructive pulmonary disease,
COPD, is a condition with a rising death rate.
According to Oregon's state health department,
in 2015 slightly more than 6% of surveyed Oregonians
said they'd been told by a healthcare professional they
had COPD in the previous 12 months. The National Heart,
Lung and Blood Institute notes that over 161,000
Oregonians have COPD.
As a chronic disease, COPD is also among the
top causes for hospital readmission rates and is a
target diagnosis for the Centers for Medicare & Medicaid
Hospital Readmissions Reduction Program. Roseburg
Oregon's 174-bed Mercy Medical Center
began a COPD Navigator program – now referred to as a
Pulmonary Disease Educator program – to help
decrease readmission rates and improve both inpatient and
outpatient care for the area's COPD patients. Initial
program design was based on a shadowing experience at an
established program in the Midwest.
Since the program's implementation in 2014, readmission
rates have decreased by almost half. One full-time
respiratory therapist works in the navigator role. Using
a color-coded, interactive tablet, the navigator can
identify admissions for patients that have a COPD
diagnosis. Patient census averages 14-20 patients and
nearly 75% are seen during their inpatient stay.
The program's three key components are smoking cessation
intervention, an evaluation for pulmonary rehabilitation
eligibility, and medication reconciliation and education.
Staffing needs include an additional full-time
respiratory therapist and another fully-trained educator
Smoking cessation education
Pulmonary rehabilitation eligibility assessment
Medication reconciliation and education, including
assessment of actual use, demonstration of proper inhaler
techniques/spacer device use, including financial issues
around affordability. (Note: This activity
typically is the most time intense, but anecdotally has
the best return on time invested.)
Oxygen needs screening
Communication with primary care
provider regarding any specific discharge
needs/medication changes identified during
Patient education materials portfolio:
Patient education materials: a large print take-home
booklet with many images (Available from an online
patient education library)
Smoking cessation guidance, including 2 online
resources for those interested and have internet access:
the state's online digital support,
Financial information for medication assistance
Information on connecting with
community resources for exercise, the local American Lung
Association's Better Breathers Club, and smoking
cessation resources through the Roseburg Community Cancer
Includes protocols for ordering
EKG, arterial blood gas (ABG), spirometry, pulmonary
rehabilitation, and discharge with Caring Continuum, a
discharge transitions of care program.
Working with the hospital's information technology team,
the Navigator created two specific tools:
Color-coded interactive tablet which identifies:
Red: 30-day readmission COPD
Yellow: COPD readmission, but past 30-day interval
Green: COPD patient admitted for another diagnosis
Blue: Smoker, not necessarily a
COPD Navigator's documentation template for
quick reference for:
Smoking cessation discussion
Medication use and instruction
30-day COPD readmission rates decreased from 27% to 14%.
Continued improvement is noted (formal tabulation
pending) due to engaging COPD patient with the "Care
Continuum Program," a discharge transition of care
Other measures planned for future assessment:
Patient satisfaction measures with COPD-specific
Quality of Life assessments
Anecdotal cases of patient satisfaction and
improved quality of life:
Navigator program's efforts led to improved mobility:
Home-based, chair-bound patient improved mobility to
be able to work in their yard without assistive device.
Wheel-chair bound patient experienced improved
mobility, tolerating a 1-hour exercise program, followed
by enough energy to walk to their car in the parking lot
without any assistance.
Connect with other established Navigator programs to
build on their successes and modify program for
Review the multiple patient education supplies
commercially available to identify educational materials
that fit your community COPD population.
Successful COPD navigator candidates should demonstrate
passion for the educational work, network with other
healthcare professionals and outpatient medical and
community service organizations that offer patient
support that fits with COPD patient needs.
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.