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BreatheBetterTogether (BBT) is a transition-to-home program that aims to reduce readmissions in patients who are hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations. Penn Medicine Lancaster General Health began a six-month pilot of the program in January, with 17 patients enrolled to date.

The BBT program engages high-risk COPD patients in daily at-home monitoring for early identification of symptoms that could signal a clinical decline. If symptoms are reported, the care team develops and implements interventions to keep patients safe and at home.

“COPD is the third-leading cause of death in the United States, trailing only heart disease and cancer,” said Matthew S. Pavlichko, MS, RRT-NPS, director, Respiratory Care and Pulmonary Diagnostics. “One in five patients hospitalized with COPD is readmitted within 30 days, although many of these readmissions may be preventable. This new program has greatly improved our readmission rate, specifically during a time when our COPD patients are at a greater risk due to the COVID-19 pandemic.”

After a hospital stay, high-risk COPD patients enrolled in LG Health’s BBT program receive a daily text message inquiring about their symptoms. If a patient responds that their breathing is worse, the BBT team is immediately alerted to reach out to the patient.

The Pulmonary Navigation Team who cared for the patient during their hospitalization conducts a phone evaluation and rapidly escalates unresolved issues to the appropriate provider. Personalized interventions may include adjustment of the medical regimen, reassurance and a timely follow-up evaluation in person or by phone.

The program’s goal of reducing 30-day readmission rates aligns with similar efforts across LG Health. Results of the pilot have been promising so far, with two readmissions to date, for a readmission rate of 11.8 percent, compared to the typical 16 percent for COPD patients. Additional benefits of the program can include shortened length of stay, as well as enhanced patient engagement and satisfaction.

The program was initially launched at the Hospital of the University of Pennsylvania, where it significantly reduced readmissions, in addition to achieving cost savings. At LG Health, the Innovation team supports a large multidisciplinary effort involving inpatient and outpatient departments. The team expects that use of similar technology will continue to expand elsewhere in the health system.

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