White Paper
COPD Patient 30-Day
Hospital Readmission
Reduction Program
Abstract: The U.S. Patient Protection and Affordable Care Act (ACA) mandates that COPD
patient readmissions to a hospital that exceed a predetermined threshold in less than 30
days from discharge will result in nancial penalties to the involved institution.
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COPD patient
readmissions prevention has been hampered due to an inadequate understanding of the
underlying problems facing both the patient and the health care provider. There are many
transition-to-home challenges and other “disconnects” that occur across the continuum of care.
Most current models of care rely solely on the use of various types of medications and devices
in an attempt to achieve the desired clinical outcomes, ignoring the chronic and behavioral
components of the disease. A new model of care is needed to focus on practical, simple and
affordable solutions to this problem. The purpose of this paper is to critically review the current
methodology with its advantages and decits and provide a fresh
look at the cause and prevention of COPD hospital
30-day readmissions.
INTRODUCTION AND OVERVIEW
Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death worldwide.
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The magnitude of the problem is increasing now that baby boomers have reached the prime
age of COPD disease manifestation. COPD is a chronic and progressive lung disease that, in
later stages, is associated with acute exacerbations (are-ups) that often occur with increasing
frequency and intensity. While there is no cure for COPD at this time, most aspects of the
disease are treatable. The current healthcare delivery model
treats patients with COPD primarily when they present in
an acute phase of the illness, but very few patients receive
active management for the chronic component. Such a
“disconnect” may be related to the U.S. national average 30-
day readmission rate of 23% for patients who are hospitalized
with a COPD exacerbation.
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In an attempt to reduce health
care costs under such circumstances, the U.S. Centers
for Medicare and Medicaid Services (CMS) has intervened
by creating nancial disincentives related to hospital
reimbursement.
Through the ACA, CMS has introduced 30-day readmission reimbursement penalties. These
penalties are geared to begin the process of moving from a “fee-for service” model in which
transitions between acute and chronic disease states can be disconnected, to a patient centric,
disease management system in which care is coordinated across the acute and chronic phases.
In a disease management system, the patients are trained and supported as they learn to
participate in the management of their illness. The ultimate goal is to reduce the occurrence and
re-occurrence of exacerbations requiring multiple hospitalizations. The purpose of this white
paper is to describe the causes of unacceptably high 30-day readmission rates and to identify
the principles and components of a methodology to prevent COPD patient readmissions.
This white paper draws upon the experiences of an expert panel, as well as conclusions from
clinical trials that have addressed the 30-day readmission problem and associated behavioral
issues related to the need for pulmonary rehabilitation.
The expert panel includes Brian Carlin, M.D., Brian Tiep, M.D., Trina Limberg, RRT, MAACVPR,
and Robert McCoy, RRT, FAARC.
Dr. Carlin is a pulmonologist in Ingomar, PA, vice-chair of the American College of Chest
Physicians, and past president of the American Association of Cardiovascular and Pulmonary
Rehabilitation. He has assisted with the development of two pilot projects that reduced COPD
30-day readmissions from an average of 23% to 5% following the intervention.
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Dr. Tiep is the Director of Pulmonary Rehabilitation at City of Hope Medical Center in Duarte,
CA and Medical Director of the Respiratory Disease Management Institute in Monrovia, CA. He
has published articles on pulmonary rehabilitation disease management, and co-authored the
American Thoracic Society/European Respiratory Society 2004 Standards for the Diagnosis and
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Treatment of Patients with COPD. He has been treating COPD patients for more than 40 years,
and his program has a 4% admission rate for COPD exacerbations.
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He holds over 15 patents
associated with respiratory care.
Trina Limberg, RRT, MAACVPR, is the Director of Preventative Pulmonary and Rehabilitation
Services at University of California at San Diego. She is a Master Fellow of the American
Association of Cardiovascular & Pulmonary Rehabilitation, has served on numerous consensus
panels and has more than 30 years of experience treating COPD patients.
Robert McCoy, RRT, FAARC, is General Manager of Valley Air Respiratory Services in
Minneapolis, Minnesota, where he conducts clinical research and testing, and is a program
development consultant.
This panel has also reviewed a number of programs and case studies that have reduced
readmissions rates, such as the DASH (Discharge Assessment and Summary at Home)
program, Klingensmith HealthCare, Ford City, PA4 and the University of California Davis Medical
Center ROAD (Reverse Obstructive Airway Disease) COPD action plan.
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In addition, the panel has
evaluated studies in aligned areas and disciplines in order to identify clinical tools that may be
helpful to address the 30-day readmission problem.
WHAT ARE THE CAUSES OF HIGH COPD 30-DAY READMISSION RATES?
Exhibit I depicts the exacerbation cascade. Exhibit II (see page 8) details the treatment
challenges associated with enabling COPD patients to avoid exacerbations and exacerbation
relapses resulting in 30-day readmissions. Those challenges can be summarized into six
categories:
1. Exacerbations are frequently not fully resolved at the time of discharge.
An inadequately treated exacerbation leaves the patient vulnerable to relapse.
2. Disjointed patient management occurs across the continuum of care. The current
system of provision of care often results in care fragmentation, such that the providers for
each step of care (e.g., outpatient primary care physician, emergency department, hospitalist)
are not suciently coordinating the overall management of an individual patient. Often there
is no designated coordinator following the patient
throughout the care plan. This lack of continuity can
result in a “discontinuum of care” in which recovery
from the acute phase is not completed, and/or the
chronic component of the disease is not managed.
The result can be a relapse and readmission,
or an admission within 30 days due to a new
exacerbation or an associated comorbidity.
3. Patient training is inadequate. Studies show that when patients get home, they may
not remember a signicant amount of information that was provided during the discharge
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process.
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And, with a lack of post-discharge follow-up by healthcare providers, a number of
vital treatment steps can fall through the cracks. For example, patients may not administer
medications correctly; they may not have their oxygen, or be suciently oxygenated; they may
have resumed smoking; and they may remain sedentary. The patient activity plan (which is
vital to airway clearance, patient conditioning and early recognition of a worsening condition)
may not be followed. In addition, saturation monitoring and airway secretion clearance steps
may not be followed. These lapses can lead to a worsening of the COPD and, ultimately,
readmission.
Disclaimer: It is understood that not all exacerbations progress in this manner or lead to tissue destruction or
remodeling (change in tissue structure or morphology).
4. Lack of professional follow-up care occurs post
discharge. 75% of patients being readmitted within
30 days have not seen their primary care provider.
3
Additionally, home respiratory care provided by a
professional respiratory therapist in the COPD patient’s
home is not reimbursed and therefore not typically
provided. Without this critical evaluation of the patient
in their environment, disconnects in treatment are not
rectied and the patient will risk having a relapse and
readmission. And, competitive bidding has made it much
more dicult for homecare companies to be able to
provide those services.
5. Equipment in the home is inadequate.
Reimbursement reductions are resulting in some
homecare providers having to source less expensive
equipment and/or equipment requiring fewer home
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Acute
Exacerbation
Cycle
Impaired
Airway
Clearance
Exacerbation
Inammation
Infection
Destruction
Airway
Remodeling
COPD Disease and
Exacerbation Cascade
• Chronic
• Progressive
• Acute exacerbations of
increasing frequency
and intensity
Layers of COPD
Disease Progression
• Lung deterioration
• Deconditioning
• Acute exacerbations of
increasing frequency and
intensity
Acute exacerbations involving inammation and infection cause tissue destruction and airway remodeling. When remodeling occurs there is a
change in the natural function of the airways. Of particular concern is a compromised ability to clear secretions and protect against infection.
Exhibit 1
The Nonin Onyx Vantage 9590 Finger
Pulse Oximeter is a small, lightweight,
portable device indicated for use in
measuring and displaying the SpO
2
and pulse rate of patients who are
well or poorly perfused.
service calls. For example, some patients may receive delivery systems that are not practical
for ambulatory use such as an E-cylinder which can weigh as much as 22 lbs. and may
be too heavy for a weak and debilitated patient. Additionally, some patients with high ow
supplemental oxygen needs may be inadequately oxygenated by some of the portable
systems in use. Both of these examples can be an impediment to the patient being active.
Activity is vital to the patient’s care plan. Equipment alone cannot accomplish clinical
outcomes and variable/limited equipment may mask the cause of an exacerbation.
6. Lack of an exacerbation Rapid Action Plan. Exacerbations are usually addressed too
late in their course so that by the time the exacerbation is detected the inammatory and
destructive processes that are part of the exacerbation are well developed. Additionally,
patients who go to the Emergency Department (ED) often experience signicant delays
in the initiation of treatment, leaving the exacerbation, and its associated inammatory
and subsequent destructive
process, unattended at a critical
and vulnerable time. The concept
here is captured in the phrase
“time is tissue”. If exacerbations
are recognized early and treated
promptly, re-hospitalization may be
averted.
PRINCIPLES OF A PATIENT-
CENTERED, CROSS-CONTINUUM,
DISEASE-MANAGEMENT APPROACH
TO REDUCING COPD 30-DAY
READMISSIONS
Traditional care plans draw a
distinction between treatment (acute)
and prevention (chronic). In fact, both
should be addressed in the overall
management of the COPD patient. A
strategy is needed that encompasses
the tools to address the disease characteristics, presentation, and patient response — both
physiological and behavioral. This panel has drawn on the successes of recent case studies
as well as their own experiences to develop a plan of care to reduce COPD patient 30-day
readmissions. The following is an overview of the principles of that program.
8,9
1. Cross-continuum of care delivery. Manage the chronic as well as the acute phases of the
disease. This requires a team that coordinates across the care continuum ensuring smooth
transitions and seamless continuation of the treatment plan.
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Patient
Primary Care,
Pulmonologist
Acute Care
Providers
Family,
Caregivers
Pulmonary
Rehabilitation,
Smoking
Cessation
Patient Centered COPD Care
a. COPD Coordinator function – this function plays
a dual role in seamlessly transitioning the patient
from the acute through the chronic phases. The
rst Coordinator role is one of educating and
training the patient and family to self-monitor
and self-manage post discharge. A Pulmonary
Rehabilitation Respiratory Therapist will have
many of the skills required of this function. The
second Coordinator role is an “extender” of the
pulmonologist; able to work across the continuum
of care, particularly post-discharge, and potentially including prescribing medications
and ordering therapy, with the goal being rapid response and relapse avoidance.
b. Ecient and effective communication between the care providers (including the
primary care physician, the ED physician, hospitalist, and pulmonologist).
c. Seamless discharge – ensure there is no interruption in the medications and care plan
from the hospital to the home.
d. Home visit – shortly after discharge to assess the home environmental factors
affecting the patient’s ability to adhere to a treatment regimen.
i. Proper equipment – adequacy of home oxygen equipment for oxygenation
(titration) and mobility.
ii. Medication reconciliation – ensure that medications prescribed by multiple MDs
are reconciled.
iii. Continue smoking cessation, assuring the availability and use of medication.
iv. Cognitive, family and nancial considerations.
2. Patient-centered care. Patient involvement in the delivery of their care is central to the
successful management of this progressive disease with chronic and acute phases. Patient
training in self-monitoring and self-managing as well as early recognition and response
to exacerbations brings this concept to life. There is a need for a mechanism for patient
collaboration with the healthcare providers.
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3. Active lifestyle. The centerpiece of successful COPD management.
a. Inactivity is destructive.
b. Activity supports overall physical and mental health, supports airway clearance and
helps with early exacerbation recognition and rapid response.
4. Patient training. Use of the “teach-back” method, in which the patient “teaches” the
clinician, enables the patient to self-monitor and self-manage while collaborating with the
healthcare provider. Pulmonary rehabilitation and patient training begins at the “inpatient”
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stage and is reinforced after the patient is discharged. The patient should have a checklist of
responsibilities and daily activities.
a. Proper administration of home meds, particularly inhaled medications.
b. Mobility and exercise – usually walking.
c. Titration of home oxygen equipment – adjusted per
SpO2 monitoring.
d. Pursed-lips breathing – may use pulse oximeter as
a biofeedback guide to increasing SpO2.
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e. Airway clearance.
f. Avoidance of smoking and exposure to second
hand smoke.
g. Avoidance of exposures to toxic perfumes, dusts,
chemicals.
5. Proper equipment. A requirement for success.
a. Metered Dose Inhaler spacer for improved administration of home medications.
b. Oxygen equipment titrated via pulse oximetry to ensure oxygenation as well as mobility
— vital to an active lifestyle.
c. Pulse oximeter for patients with oxygen desaturation. This is useful in physician-
directed oxygen titration as well as a biofeedback guide for pursed lips breathing.
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d. Airway clearance devices.
6. Rapid Action Plan. Early intervention is the key
to successful exacerbation resolution and relapse
avoidance.
a. Patients should be trained to recognize
the early signs of an exacerbation or an
exacerbation relapse. This includes greater
than usual dyspnea upon the same exertion
and change in sputum. When recognized, the
Rapid Action Plan begins: call doctor; start steroids, antibiotics, bronchodilators and
uids; adjust oxygen; and engage in pursed lips breathing.
b. A checklist-procedure should be in place for specic interventions by the patient,
physician, ED physician, hospitalist, and COPD coordinator.
c. Begin medications with many patients as early as possible, including while they’re still
at home. Have medications on-hand. Time is tissue.
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7. Pulmonary rehabilitation, smoking cessation. Since the patient is experiencing the worst
aspects of the disease in the hospital, this is likely to be a “teachable moment.” Smoking
cessation (including medications) and pulmonary rehabilitation should start in the hospital.
Generally recommended for smoking cessation is either Chantix or nicotine replacement
therapy with nicotine patch and a rapid acting nicotine replacement, like gum or a lozenge.
SUMMARY
In summary, successfully instituting a plan of care that will ultimately lower the COPD patient 30-
day readmission rate positions the healthcare provider and system to succeed in this new, pay-
for-performance healthcare paradigm. Successful management of the COPD patient embodies
healthcare’s “Triple Aim” — outcomes are improved, per capita costs are lowered and people
living with COPD can experience fuller, longer, and more active lives.
Exhibit II
COPD TREATMENT CHALLENGES: PROBLEMS WITH USUAL CARE
MANAGEMENT
Acute:
• Active treatment occurs only during acute exacerbation.
• Time-sensitive treatment is frequently delayed.
Chronic:
• The chronic component often is not
addressed.
• Even when the patient gets pulmonary
rehabilitation, it is a short-term solution for
a problem that is lifelong, progressive and
gets worse over time.
• How patients manage their care at home
can make the greatest difference in
disease control.
A COPD exacerbation is a dynamic process leading
to destruction and airway remodeling. Thus it is
time sensitive (time is tissue). When destruction
occurs, repair takes longer and tissue may not fully
repair. This can lower the baseline status, rendering
a future exacerbation more likely.
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FACTORS CONTRIBUTING TO HOSPITALIZATION AND READMISSIONS
Lack of predetermined Rapid Action Plan:
• Symptoms are unrecognized or may be ignored for
days or more.
• Lack of early access to a physician.
• Delayed response can lead to tissue destruction,
airway remodeling and progression beyond simple
control.
Emergency Department response:
• Response can often be inadequate because there
are treatment delays or there can be insucient
treatment intensity. When treated promptly,
admission/ readmission of the COPD patient can be
avoided.
• Steroid treatment is often too little, too late and, as a result, too long. Thus side effects of
long-term steroid use become more likely.
• There is often a delayed start for IVs, steroids, antibiotics and/or bronchodilators. To
avoid treatment delay, it is important to educate the Emergency Department that active
treatment can often start prior to arterial blood gas draws or chest x-rays.
In-patient treatment:
• Treatment (particularly respiratory therapy and secretion mobilization) may commence
slowly, lack intensity, or be delayed.
• Patients often are not ambulated (mobilized) while in the hospital. Activity is very
important in COPD management.
• Smoking cessation often is not addressed in the hospital and therefore education and
medications to aid in successful cessation may not be provided. Thus smokers will most
likely re-start smoking as soon as they get home.
• Prior to discharge, intravenous medications may not be adequately converted to oral
medications with instructions for administration at home.
• Patient training for long-term management of COPD has not begun.
Discharge/transition to home care:
• Acute exacerbations often require more than the 3-5 day length of stay for resolution.
This can leave the patient vulnerable to relapse if the treatment is interrupted or
inadequately continued at home.
• Intravenous medications may not be converted to oral medications before discharge.
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• Inhaled medications may still be administered through nebulizers and not converted to
meter-dose inhalers, and/or nebulizers may not be provided for home administration of
bronchodilators.
• Interruption of medication between in-patient and home care.
• Medications may not be available at home.
• Medication administration instruction may be inadequate.
• No follow-through on smoking cessation plan, including medication adherence.
Home care COPD management – nish exacerbation treatment and proceed to address the
chronic component.
• Inadequate outpatient management assuring that the exacerbation is fully resolved.
• Inadequate training for managing the chronic component of COPD.
• Inadequate medication and/or training on medication administration.
• Failure to reconcile home medications prescribed by different providers.
• Inadequate instruction on proper airway clearance.
• Inadequate titration of home oxygen and portable oxygen devices.
• Inadequate monitoring of oxygen saturation.
• Sedentary lifestyle resulting in inadequate mobilization
• Re-started smoking at home.
• Inadequate home care monitoring.
• Lack of follow-up physician appointment.
CONCLUSION
A COPD exacerbation is a serious event that can be disabling and even life threatening.
Prevention as well as proactive intervention at the rst sign of an exacerbation is important. The
keys to success are making sure there is early recognition of the exacerbation, avoiding delays in
treatment, and treating with adequate intensity. Often we do not see the exacerbation through to
resolution, thus leaving an active process smoldering. Post exacerbation, these patients should
be monitored more regularly since a previous exacerbation portends the next exacerbation.
A COPD exacerbation is a dynamic process leading to destruction and airway
remodeling. Thus it is time sensitive (time is tissue). When destruction occurs, repair
takes longer, tissue may not fully repair. This can lower the baseline status, rendering a
future exacerbation more likely.
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REFERENCES
1. Rau, J. A Guide to Medicare’s Readmissions Penalties and Data. Kaiser Health News. Oct 2, 2014
2. Hoyert DL, Xu JQ. Deaths: preliminary data for 2011. Natl Vital Stat Rep. 2012;61(6):1-65
3. Jenks S, Williams M, Coleman E. Re-hospitalization among patients in the Medicare fee-for-service program. N
Eng J Med. 2009; 360:14
4. Carlin BW, Wiles K, Easley D. Transition of Care and Rehospitalization Rates for Patients Who Require Home
Oxygen Therapy Following Hospitalization.
Eur Respir J. 2012; 40(Meeting Abstracts):P617
5. Tiep B, Barnett M, Carter R; Lifetime management of COPD via a Clinical Guidance System: 12th year of a
continuous care model. Am J Respir Crit Care Med. 189;2014:A1910
6. Young MS, Craddock KM et al. COPD training by respiratory care practitioners decreases healthcare utilization
and improves patient outcomes. Am J Respir Crit Care Med. 189;2014:A5943
7. Calkins, DR, Davis, RB, Reiley, P et al. Patient-physician communication at hospital discharge and patients’
understanding of the postdischarge treatment plan. Arch Intern. Med. 1997; 157: 1026–1030
8. Tiep B. Disease management of COPD with pulmonary rehabilitation. Chest. 1997;112:1630-1656
9. Tiep BL. In: Celli B, McNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of
the ATS/ERS position paper. Eur Respir J. 2004; 23: 932–946
10. Tiep B, Barnett M. Disease management for chronic obstructive pulmonary disease, A clinical approach. Dis
Manage Health Outcomes. 2008:16(5):305313
11. Tiep BL, Burns M, Kao D, Madison R and Herrera J. Pursed lips breathing training using ear oximetry. Chest.
1986; 90:218-221
