Breathing Easier When a Lung Health Outpatient Team Has Your Back

Abstract

Background:

The goal of this program is to improve the quality of life in COPD patients. An outpatient resource center provides post-discharge follow-up to facilitate continuum of care. Frequent readmissions are common in the COPD patient population and have become a focus of the CMS value based measures. Research has shown there to be a 7. 1% 30-day readmission rate for a principal diagnosis of COPD and a 20.5% for all-cause 30-day readmission. Understanding the disease process and progression is key if patients are to receive the maximum benefit from their medications. Many of these patients have comorbidities which leads to complicated medication regimens. An early follow-up process is recommended by the Global Initiative of Chronic Obstructive Lung Disease to lessen exacerbation related readmissions. Upon discharge, many of these patients are not back to their baseline and are unclear about their treatment regimen. According to the Institute for Safe Medication Practices, 94% of patients with COPD and asthma use their inhalers incorrectly which can lead to a reduction of efficacy and poor outcomes. Intensive outpatient monitoring, evaluation, and education are needed to prevent readmissions.

Methods:

A lung-health outpatient clinic was assembled with a multidisciplinary team. The goal is to improve the quality of life and decrease readmissions through the continuum of care. Prevention strategies are initiated. Pharmacological and non-pharmacologic interventions are used to complement the individual's treatment goals. The multi-disciplinary team headed by the respiratory department, scheduled appointments at the lung health outpatient resource clinic, prior to discharge. During the appointment, the ARNP, RT, and RN evaluate the patient and provides treatment as needed. Education about the COPD disease process and self-management are provided by the respiratory therapist. The team helps identify and reduce exposure to internal and external risk factors. If further interventions are indicated, physicians are notified.

Results:

The program started in June of 2017 and data was collected for 9 months. A total of 56 patients were seen in the outpatient clinic; 5 were readmitted for all cause diagnosis and zero were admitted for COPD exacerbation.

Conclusions:

An outpatient lung health clinic made a significant impact in the reduction of COPD readmission rates.