Reducing COPD Readmission Rates Using an Interdisciplinary Collaborative Care Model

Abstract

Background: Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of morbidity and mortality. COPD is included in the Hospital Readmissions Reduction Program (HRRP), a Medicare value-based purchasing program that penalizes hospitals for 30-day readmissions. Implementation of cost effective care methods to prevent readmissions has become a greater challenge for many health care systems. Such challenges include identification of gaps between the inpatient and outpatient care settings; that would allow for continuity in respiratory care and other pulmonary rehabilitation modalities. In fiscal year 2018, the overall 30-day readmission rate for Medicare Fee-For-Service (FFS) patients with COPD was 26.4% with 52% of these readmissions being within 7 days of discharge. Continuity of care between the inpatient and outpatient care areas is imperative to achieving a successful HRRP, while improving quality of life for the patient. Methods: We implemented COPD Transitional Care Coordination (TCC) as a strategic model of promoting efficient collaboration between the inpatient and outpatient care settings. For in-patient care, the model includes, a COPD Action Plan and interdisciplinary collaboration to formulate efficient care, with appropriate outpatient referrals (i.e., smoking cessation, pulmonary rehabilitation). For out-patient care we established post-discharge follow up telephone calls, via a health care navigator (HCN), per inpatient respiratory care practitioners (RCPs) assessments and recommendations. The HCN provided continual information sharing between outpatient practitioners to allow for further referrals and collaboration of care; reinforcement of the COPD Action plan and inhaler reconciliation. Results: A total of 177 patients were seen for COPD Action Plan as part of our COPD TCC model. Between August 2018 and May 2019, 13% of the COPD TCC patients seen were successfully enrolled with the ambulatory palliative care program for additional layer support, 8% of patients were referred for pulmonary rehabilitation. Conclusions: Active collaboration between all patient care areas plays an important role in promoting efficient patient care. Utilization of tools such as a COPD Action Plan allows for better patient engagement, leading to a better patient outcome.