How Can Implementing COPD Management Impact Hospital Readmissions?

For those living with chronic obstructive pulmonary disease (COPD), regular disease management is critical to maintaining good health. When COPD symptoms are not managed properly and become worse, those living with COPD can experience complications that can have a negative impact on their overall quality of life, such as difficulty breathing, severe exhaustion, and more. With COPD management practices like healthy lifestyle changes, taking prescribed medications or treatments, and continuously monitoring symptoms, patients can both improve their conditions and reduce the risk of exacerbating symptoms. With improved health outcomes, patients will also significantly reduce their risk of being hospitalized.

 

Female doctor virtually consulting COPD patient

Reducing Hospitalizations With COPD Management

When it comes to treating patients with any illness, keeping them out of the hospital and ensuring their symptoms are under control is a top priority for all healthcare providers. When patients are admitted to the hospital due to worsening health conditions, it can take a negative toll on them and their loved ones. Not only are hospitalizations difficult for patients and those who care for them, they also have a negative impact on our healthcare systems. Although readmission rates for patients living with COPD tend to be higher than those with other illnesses, there are proven measures that can reduce the likelihood of readmission. This blog will highlight the importance of COPD patient management, and its impact on hospital readmissions.

Allows Patients to Self Monitor and Recognize Symptoms

As a part of self-management training for patients with COPD, it is important to educate them on what symptoms to take note of, and when they should be reported. When COPD symptoms are caught early on, the risk of patients being admitted to the hospital decreases significantly. By having patients self-monitor and track their symptoms, they can become more familiar with regular changes in their condition, and learn the appropriate measures to take as soon as symptoms begin worsening to avoid hospitalization.

With management tools such as virtual COPD care pathways that can be accessed from anywhere, patients can access resources to help identify symptoms, and input these changes into their platform to notify their care team. With many platforms, patients’ symptoms can be easily identified through automated care plans which can trigger an automatic response providing the next steps a patient should take. Patients can then take immediate action to make changes to their routine, or request a virtual or in-person healthcare visit to create a plan to mitigate their symptoms with the help of their care team.

Allows Providers To Quickly Respond to Changing Symptoms

Virtual meeting with doctor

COPD is a life-long illness that, if treated and managed early on, can remain manageable. That being said, every patient’s journey with COPD will be different, and it is more common than not that the severity of each patient’s symptoms will fluctuate over time. When patients are able to identify and report changing symptoms early on, their healthcare providers can begin addressing any issues before their condition becomes worse.

Patients are not always aware of the signs that their symptoms are becoming severe because they often don’t know what to look for. With effective COPD management, patients will routinely check in with their healthcare provider and update them on their symptoms. This allows their care team to identify symptoms that could lead to exacerbation early on, providing them valuable time to take the necessary steps with their patients to improve their condition and avoid a visit to the hospital.

Allows Patients To Connect With Members of Their Care Circle When Needed

Friends hugging each other

Patient care circles can include family members, healthcare staff, specialists, and other individuals who are responsible for ensuring they are continuously managing their illness. While having a large care circle can greatly benefit patients and help with their disease management, it can sometimes be difficult to keep all members in the loop. Furthermore, many patients who live in rural communities can face challenges connecting with members of their care circle in person due to difficulties travelling.

Unfortunately, these challenges can often lead to patients delaying important healthcare visits. If problematic COPD symptoms are ignored for too long, patients face an increased risk of experiencing a flare-up and being admitted to the hospital to treat their condition. To overcome this, healthcare providers can utilize virtual care pathways to help patients stay connected with their care circle at all times. With platforms such as aTouchAway, all chosen members of a patient’s care circle can receive regular updates on the status of their health. Patients can also speak directly with their healthcare provider through the platform to begin taking the necessary steps to improve their condition without having to wait for, or travel to, an in-person appointment.

Motivates Patients To Continue With Their Progress

Patient motivation plays a critical role in improving health outcomes and reducing hospitalizations. Unfortunately, when patients are admitted to the hospital due to COPD symptoms that have become too difficult to manage on their own, it can negatively impact their outlook on the future of their illness. For this reason, motivating patients to continue with their progress is essential to improve their long-term health outcomes.

One way healthcare providers can help motivate patients to continue with their progress is by providing them with effective management tools and proper support. One study found that with regular contact and support from patients’ care circles, they are more likely to increase their physical activity and improve their health. As patients begin regularly taking measures to better manage their illness and have the support they need, the likelihood of their symptoms progressing to the point of requiring hospitalization continues to decrease.

Benefits of Reduced Hospitalizations

Hospital staff consulting

Reducing hospitalizations for those living with COPD can have a positive impact on the lives of patients and our healthcare system. Thankfully, with advancements in healthcare and more research being put into COPD management, there are many things healthcare providers can do to ensure quality care for their patients and reduce the need for hospital admissions.

When patients are admitted to the hospital, there is an increased risk of them being readmitted shortly after, especially within the first year. In a journal published by Arch Intern Med, their research found that 9% to 48% of all hospital readmissions could have been prevented if the care patients received while in the hospital and after their discharge was handled differently. Arch Intern Med’s journal also states that hospitalizations account for roughly half of all healthcare expenses, and that just 13% of hospitalized patients in the U.S require more than half of all hospital resources when they are continuously readmitted.

These statistics make it clear that reducing the number of hospital admissions for patients living with COPD can free up valuable healthcare resources and reduce strain on already overwhelmed healthcare systems. Patients can also benefit greatly by having more control over their health and will experience an improved quality of life when they are less likely to be hospitalized.

By ensuring patients are equipped with the right tools to effectively manage their COPD, and with continuous support, healthcare providers can help reduce the number of hospital admissions and readmissions their patients’ experience.

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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