How a customized COPD care bundle is reducing readmissions

Reducing readmissions for chronic obstructive pulmonary disease (COPD) is an ongoing challenge for healthcare systems.

One success story is the University of Cincinnati Medical Center. Before starting its new COPD care program, its readmission rate for COPD within a 30-day period after discharge was about 23%. Now it is about 14%.

Managed Healthcare Executive (MHE) asked Jonathan Ko, BS, RRT-NPS, AE-C, clinical manager for respiratory care at the hospital, to elaborate.

MHE: What inspired your institution to implement a customized COPD care bundle?

Ko: We wanted to ensure that we were following best practice methods for patient care to prevent readmissions. We sought to keep patients out of the hospital as much as we could.

Being an intercity hospital and a safety-net hospital, we are tasked with a large indigent patient population. Our challenge was to balance the cost of the prescription drugs that patients need to routinely take with finding a provider that they could visit instead of using the emergency room, which they often do because of lack of insurance.

MHE: What have you achieved since starting the care bundle program about two years ago?  

Ko: Before starting, our readmission rate for COPD within a 30-day period after discharge was about 23%. But now we have roughly a 14% all-cause readmission rate [for these patients].

We began by asking patients what their needs were. Also, once a physician makes a definitive diagnosis of COPD, a series of steps are triggered. For example, the respiratory department shares tailored inhaler education with the staff, based on what the patient is going home on, because we know that hospital formulary drugs sometimes differ from what insurance will pay upon patient discharge.

Further, patients are provided a visual sheet and a handout about inhalers, as well as a live demonstration with demo inhalers, before discharge.

In addition, patients are oriented as to which drugs to use when they are having an emergency versus which drugs to use on a daily basis. Counseling patients on the side effects and complications of the drugs they take home is covered too.

MHE: Any other discharge instructions?  

Ko: We have a standardized discharge instruction, also generated by the respiratory department. The trifold handout consists of three sections. The first section is a checkbox of what patients should request or anticipate receiving before discharge, including a follow-up appointment with their primary care physician and ensuring patients have medication prescriptions.

The second section lists signs and symptoms that patients should look for following discharge if they have trouble breathing or need to see a doctor. For trouble breathing, steps are listed, like taking their rescue inhaler, along with oral steroids like prednisone if you have them.

The third section of the trifold is left blank so patients can write a list of their discharge inhalers. 

MHE: Is social work part of the bundle program as well?

Ko: Yes. Besides the social and financial aspects of discharge, however, our social workers ensure that patients make a follow-up appointment with a primary care doctor within seven days of discharge if possible. But if the patient does not have access to a doctor, we schedule an appointment with one of our hospital primary care physicians.

Another component of our bundle is pharmacy, both inpatient and outpatient pharmacy, to identify insurance-compatible inhaler brands. Our pharmacy also fills a 30-stay supply of medicine for the inhalers that are taken home.

We plateaued in our reduction in COPD readmissions about six months ago. And going forward, we do not expect a variability in this reduction.

Nonetheless, the bundle program has been slightly challenging to institute because there are so many moving parts. We have taken a more holistic approach consisting of a large, multidisciplinary team, whereby we have essentially put aside our differences and have agreed on the evidence out there for reducing readmissions.