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Rural Health Information Hub

Genesis HealthCare System

  • Project Title: COPD Readmission Prevention Program
  • Program Representative Interviewed: Rob Williamson, RN, BSN, CRN, Pulmonary Nurse Navigator
  • Location: Zanesville, OH
  • Program Overview: Genesis HealthCare System seeks to prevent hospital readmissions among their COPD patients through a comprehensive care coordination and patient education program. Nurse navigators track patients while they are admitted to assess their COPD severity, offer tobacco cessation counseling, and provide education about various components of COPD causes, diagnosis, and treatment. Nurse navigators also assess for outpatient needs such as transportation, ability to afford medication, and access to healthcare providers. The nurse navigators then provide resources to help meet those needs. Nurse navigators continue follow-up after discharge through phone calls and as-needed home visits. COPD patients can also be enrolled in the system's lung clinic, which is dedicated to treating respiratory diseases. Patients enrolled with the lung clinic have the additional benefit of a federal grant funded medication assistance program which can provide respiratory medications at no cost to those who qualify. This program allows prescription respiratory medications to be picked up same-day at the onsite pharmacy. Beyond the clinical setting, the COPD Readmission Prevention Program has helped to develop a reserve-a-ride service in conjunction with their local public transportation system, South East Area Transit System (SEAT), which can coordinate transportation for patients between medical appointments. This program has inspired readmission prevention programs specific to other conditions in Genesis HealthCare System, such as congestive heart failure and stroke.

Read about the COPD Readmission Prevention Program in RHIhub's Rural Health Models and Innovations.

Models represented by this program: