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Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions

A chronic obstructive pulmonary disease care service improves timely access to follow-up care and patient education at the time of transition from hospital to home.
Federal Practitioner. 2018 November;35(11)a:30-36
November 5, 2018|Federal Practitioner
Edward C. Portillo, PharmD;Andrew Wilcox, PharmD;Ellina Seckel, PharmD;Amanda Margolis, PharmD;Jean Montgomery, MD;Prakash Balasubramanian, MD;Geri Abshire, MSN, RN;Jim Lewis, RRT;Christopher Hildebrand, MD;Sameer Mathur, MD;Alan Bridges, MD;Sujani Kakumanu, MD
Author and Disclosure Information

Edward Portillo is a Clinical Pharmacist Specialist, Andrew Wilcox is Chief of Pharmacy Services, Ellina Seckel is Acting Chief of Primary Care and Associate Chief of Ambulatory and Specialty Care, Amanda Margolis is a Clinical Pharmacist Specialist, Jean Montgomery is a Physician in Primary Care, Prakash Balasubramanian i s a Hospitalist, Geri Abshire is the Northern Tier Clinic and Nurse Manager-Primary Care, Jim Lewis is Chief of Respiratory Therapy, Christopher Hildebrand is the Associate Chief of Staff for Education and Ambulatory Care, Sameer Mathur is Associate Professor in the Division of Allergy, Pulmonary and Critical Care Medicine, Alan Bridges is Chief of Staff, and Sujani Kakumanu is Chief of Allergy, all at the William S. Middleton Memorial Veterans Affairs Hospital in Madison, Wisconsin. Edward Portillo and Amanda Margolis are Clinical Assistant Professors at the University of Wisconsin-Madison School of Pharmacy. Christopher Hildebrand and Alan Bridges are Clinical Professors in the Department of Medicine, and Sameer Mathur is an Associate Professor at the University of Wisconsin-Madison School of Medicine and Public Health.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Patient Referrals

Patient referrals also were a critical component of the COPD CARE service. Pharmacists placed referrals for tobacco treatment services, pulmonary rehabilitation, a COPD group education class, and referral to specialty care if needed.

Inhaler Technique Review

Either the pharmacist or RN review the inhaler technique, and corrections and teachback methods used to ensure patient understanding.23 Patients were encouraged to bring home inhalers into clinic for technique assessment. Demonstration inhalers also were available and used by pharmacists and nurses for inhaler teaching as needed. The pharmacist indicated through chart documentation whether the patient’s inhaler technique was correct or whether modifications were made to improve medication delivery. Medication reconciliation also was performed for inhaled devices to insure patients were using medications as prescribed.

Outcomes

The primary outcome of this evaluation was an assessment of interventions made by the interprofessional care team during the COPD CARE health visit. Secondary outcomes included assessment of 30-day readmission rates as well as patient access to the primary care team using this interprofessional care model.

Data were collected after study completion through review of the EHR at baseline and at the end of the evaluation period. Baseline demographic information was collected through a retrospective chart review. Readmission rates were calculated as a composite of ED visits and rehospitalization within 30 days of discharge due to a COPD exacerbation.

Patients’ spirometry results were used in composite with clinical symptoms and risk of exacerbations to calculate GOLD staging.24

Results

A total of 19 patients admitted to the hospital or ED received follow-up through the COPD CARE service. Patients included in this analysis were primarily older adult white males.

Referrals were placed for 53% of patients in the COPD CARE service, with 21% of patients accepting referral to tobacco treatment clinic, and 32% of patients accepting referral to pulmonary rehabilitation. COPD plans were issued to all of patients in this service. Pharmacists modified therapy 58% of the time, with a review of medications prescribed by the clinical pharmacist (eApendixes 1 and 2, available at mdedge.com/fedprac).

Patients had a 0% composite readmission rate to the ED or hospital for a COPD exacerbation within 30-days of discharge. Access to care, defined as a visit with the primary care PACT team within 30 days of discharge, was achieved in 14 of the 19 patients (73.7%). Additionally, 12 of 19 patients (63.2%) in the COPD CARE service no longer needed to see their PCP following discharge, saving their provider a visit.

The pharmacist corrected patient inhaler technique in 52.6% of the patients participating in the service.

Discussion

The intent of this QI initiative was to assess a novel clinic intervention for a high-risk patient population during COPD care transitions. The strengths of this intervention involved a rapid cycle implementation using the existing medical home model and its multiprong approach to coordinating care. This approach involved coordinating self-direction COPD plans, timely hospital follow-up, and the innovative use of the interprofessional primary care team.

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