Abstract
Background: COPD is the third-leading cause of death in the United States and 20% of patients readmit within 30 d; many of these readmissions are preventable. The current paradigm only allows patients to see providers when appointments are available, not when they need us. BBT is an innovative transition-to-home program that connects patients to a pulmonary navigator (PN) who helps identify early onset of symptoms and implement proactive interventions. Developed by our partners at Penn Medicine Hospital of the University of Pennsylvania (HUP), the program significantly decreased readmissions. Penn Medicine Lancaster General Health (LGH) adapted BBT in a new context to duplicate the results seen at HUP, launching a 6-month pilot program beginning January 2021.
Methods: The PN identifies eligible, hospitalized patients with a COPD diagnosis. During the admission, the PN educates and prepares the patient for successful discharge and follows up with a phone call at 48 hours. Post discharge, enrolled patients receive a daily text at 10:00 am Monday–Friday to evaluate their breathing and identify early clinical decline. Patients respond either A (breathing is better than usual), B (breathing is same as usual) or C (breathing is worse than usual). A worse response (C or Call) triggers an immediate alert to the PN who conducts a phone evaluation within 30 min to assess symptoms, provide treatment guidance, and/or triage care based on the escalation algorithm.
Results: Since the beginning of the pilot, the PNs have reviewed 234 COPD patients for BBT eligibility. BBT enrollment rate was 55.4% (36 enrolled/65 offered). All patients who responded worse received a return call within the 30-min goal and were thoroughly assessed by the PN. Thirty day readmissions in the pilot group occurred at a rate of 11.1% due to breathing difficulties, compared to pre-BBT intervention rate of 11.7%. It was estimated that 17 emergency department visits were mitigated by the BBT escalation algorithm.
Conclusions: Although readmission rates did not significantly decline for those with breathing difficulties, the BBT program at LGH represents the evolution of an innovative, evidence-based intervention that is effective and scalable. It is an easy application that allows patients to interact with a PN when services are needed, not when they are available. Continued research is needed to identify how telemedicine interventions can affect the overall health of this vulnerable population.
Footnotes
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