Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death in this country. While patients receive comprehensive care during a hospitalization, “the level of care and support drops off dramatically when patients transition to home,” said Vivek Ahya, MD, clinical director of the Harron Jr. Lung Center.
“Patients often do not have a good understanding of what to do when they start feeling worse or how to use their medications optimally.” So it’s not surprising that 20 percent of these patients get readmitted within 30 days of discharge, “many within 10 days.” Yet, many of these re-admissions are preventable.
Now, Transitions in Care, a new pilot study on Silverstein 11 which focuses on standardizing the transition of care to home with a pro-active approach to education, significantly dropped 30-day readmission rate of patients with COPD. Indeed, for the first quarter of FY18, they had no 30-day re-admissions at all!
According to respiratory therapist Colleen Cain, RRT, COPD educator, the personalized education process, which starts the day COPD patients are admitted to the unit, includes “why they’re taking certain medications, how to take the medications, and breathing techniques to follow if they have an episode of shortness of breath at home,” Cain said. During the pilot, the education continued daily while at HUP and then transitioned to a Caring Way nurse from Penn Home Care and Hospice who provided the same education for patients at home. Cain also called these patients two days after they left HUP to reinforce and verify the information, including that they have their meds, know what to look for in a flare up, and have scheduled follow-up appointments.
An Innovation Accelerator Grant from the Penn Center for Health Care Innovation will help them expand the Transitions in Care initiative to all COPD patients admitted to HUP, which averages about 200. “Our goal is to educate all our patients on how to manage this chronic condition at home,” Cain said.