Finding the Value of a Respiratory Therapist Home Visit Program for COPD

COPD affects nearly 16 million (6.4%) Americans.¹ Many adults (50%) with poor pulmonary function are not aware they have COPD, likely increasing the number of individuals affected with the disease.² COPD exacerbations result in roughly 700,000 hospitalizations and 1.5 million emergency department visits annually and is the third leading cause of death in the United States.^3-5 Complications from COPD include activity limitations, poor quality of life, need for home care equipment, increased memory loss, clinical depression, and poor health status.⁶

Despite health care providers and health systems efforts to broadly follow the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, the economic burden of COPD remains around $50 billion in direct and indirect costs.⁷ Approximately one in 5 COPD hospitalizations have a 30-day readmission with an estimated annual health care cost of $15 billion.^8,9 The most frequent reasons for 30-day readmissions for COPD are age, socioeconomic status, poor device technique, and comorbidities affecting COPD.¹⁰

In 2015, the Centers for Medicare and Medicaid Services implemented a performance measure as a financial incentive for hospitals and health systems to evaluate the spectrum of care for patients with COPD. The intent of this incentive was for hospitals to incorporate different care models that would decrease 30-day readmissions.¹¹ This performance measure has forced health care providers and health systems to eva-luate current processes and be innovative in creating new approaches to health care. One of those innovative approaches is looking at ways to incorporate a home visit program into their bundled payment model where a single payment is provided for a population of patients for an episode of care that includes up to 30 days after the index visit.

For several decades, home visit programs for prenatal and pediatric care have been found to be an effective intervention to improve health and well-being of patients.¹² Home visit programs that include coaching, education, and patient-centered care have been found to improve access to supportive care, increase individual activity, improve medication and plan-of-care adherence, and decrease health care utilization for individuals diagnosed with COPD.^13-15

The study in this issue of the Journal¹⁶ did a retrospective chart review of 2 separate groups of subjects ≥ 65 y old with a diagnosis of COPD who had a hospitalization at one of 5 hospitals in the New Jersey area. The investigators compared 30-day, 60-day, and 90-day readmission rates between the pre-intervention and the post-intervention groups. They hypothesize education around earlier recognition and treatment of a COPD exacerbation can decrease hospital readmissions.¹⁶ The pre-intervention group consisted of subjects who were admitted for COPD to one of the 5 hospitals between January 2016–March 2017. The pre-intervention subjects received standard of care while in the hospital, but some may have received a telehealth follow-up after discharge.¹⁶ The post-intervention group consisted of subjects who were admitted for COPD to one of the 5 hospitals between April 2017–September 2019. The post-intervention group received standard of care at the facility but then was referred to a respiratory therapist (RT)–led home visit program after discharge. The RT would contact the subject within 2 business days of discharge to schedule at least 3 home visits (up to 5 if needed) over a 4-week period. During the home visit, the RT would provide COPD self-management education, nutritional counseling, and smoking cessation (if applicable); review the individual COPD action plan; train on proper inhaler technique; complete the COPD assessment test; reinforce the importance of pulmonary rehabilitation and medication reconciliation; and assist with coping methods for anxiety/depression. Any barriers identified impacting the subject’s ability to follow the plan of care would be addressed in partnership with the RT and pulmonologist. Referrals were placed to other providers as needed.¹⁶

The investigators found implementation of an RT home visit program after discharge significantly reduced 30-day, 60-day, and 90-day readmissions for COPD by attaining timely communication, establishing patient home health goals, attempting earlier integration into a pulmonary rehabilitation program, identifying barriers to care, and reinforcing in the importance of follow-up.¹⁶

Drawing a firm conclusion from this study that a post-discharge RT home visit program for COPD will decrease avoidable readmissions is difficult for a several reasons. First, this was a retrospective study, so there are risks of confounding and selection bias. Second, the investigators stated that subjects were selected from a patient population with high health care utilization for their COPD, but none of the data shared in this study clearly defines what is considered high health care utilizers. Third, it is unclear the number of subjects in the pre-intervention group who may have received a telehealth visit post discharge in addition to standard of care within the facility. Studies have shown telehealth/telemedicine visits can have similar positive outcomes, and this could have been a variable affecting the pre-intervention group. To minimize variability in the pre-intervention group, it would have been best to remove the subjects who received telehealth followup after discharge. Fourth, it is worth a deeper dive into looking at subject-reported ethnicity to ensure the pre-intervention group was adequately captured within the data. Fifth, the available data are limited by only looking at basic demographics, smoking status, and readmission rates. Case mix index, previous health care utilization trends, and disease severity defined by GOLD guidelines could help differentiate severity of the illness potentially impacting readmissions. Also, medication adherence, attendance to follow-up appointments, quality-of-life assessments, medication refills, participation in a pulmonary rehabilitation program, and ongoing proper device technique assessment can further evaluate each of the intercessions the RT had with the subject. Sixth, estimated cost savings through the reduction in readmissions with the home visit program group can help illustrate if there was a return on investment, particularly since the context of this study was framed around the Hospital Readmissions Reduction Program through Medicare. Seventh, it is also important to recognize 10–55% of COPD readmissions are preventable.¹⁷ These other confounding factors (inappropriate care during or after the index admission, premature discharge, comorbidities, severity of disease, lack of communication between health care team members, and long-term social support for the patient) can be major contributors to readmissions for COPD.^18,19

The investigators did recognize difficulty in connecting with potential subjects post discharge and maintaining ongoing communication throughout the 4-week intervention as limitations to the study. Also, subjects may have sought health care outside of the 5 hospital systems, potentially impacting the readmission outcome metrics.

Future studies could include a prospective approach of randomizing subjects with and without the intervention and a more comprehensive comparative analysis looking at demographics, smoking habits, disease severity, case mix index, and prior health care utilization as additional contributors to overall outcome based on each intervention. It will also be important to track direct and indirect return on investment including cost savings that can be reported out for the benefit of other institutions looking to implement a home visit program that can be shared with payers who are looking to partner with institutions on a bundled payment model.

Reducing avoidable health care costs can best be achieved through education and prevention. Underutilized preventive services result from a of lack of knowledge around the recognized indirect benefit to the patient, and through those indirect benefits, reduction in unnecessary health care expenditure can be achieved through innovative approaches toward education and prevention.

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