COPD Inpatient Navigator Program
- 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, or 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 Services Hospital Readmissions Reduction Program. Roseburg Oregon's 174-bed Mercy Medical Center began a COPD Navigator 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 for backup.
- 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 hospitalization
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: BecomeanEX and the state's online digital support, Quit Line
- 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 Center.
Prebuilt order set:
- Based on Global Initiative for Chronic Obstructive Lung Disease guidelines (GOLD)
- 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 patient
COPD Navigator's documentation template for quick reference for:
- Overall assessment
- 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 program.
Other measures planned for future assessment:
- Patient satisfaction measures with COPD-specific education
- 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 implementation.
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.
Contact InformationJeffery Wuerst RRT, COPD In-Patient Navigator
Mercy Medical Center, Roseburg, Oregon
Chronic respiratory conditions
June 18, 2018
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.