Pulmonary Disease Navigator

Patient Assessment and Education Reduces Length of Stay

Background

More than 700,000 patients with Chronic Obstructive Pulmonary Disease (COPD) experience exacerbations resulting in hospitalization. Additionally, mortality rates increase 3-fold as exacerbation frequency increases from 0 to 3 or more per year³. COPD accounts for roughly 20% of all 30-day readmissions, making it the third leading cause of readmissions in the United States². Furthermore, COPD is often misdiagnosed, leading to inadequate symptom management and significant healthcare costs of $49 billion in 2022⁴. Spirometry is required to diagnose COPD, and a post-bronchodilator FEV1/FVC ratio of less than 0.70 or Lower Limits of Normal confirms the presence of persistent airflow limitation and a diagnosis of COPD¹. An internal review found that poor chronic disease management often results from an inadequate home regimen, incorrect diagnosis, or poor adherence to the patient's care plan.

Intervention Detail

PIH Health Whittier Hospital Respiratory Department developed and implemented a Pulmonary Disease Navigator (PDN) program to reduce COPD readmissions and length of stay (LOS). Patients were identified through the EMR based on COPD and related ICD-10 diagnoses and Physician, Respiratory Therapists, Nursing, and Case management referrals. The PDN process begins by identifying the cause of admission by performing an objective and subjective patient assessment to identify deficiencies in chronic disease management. The evaluation consists of spirometry, when not contraindicated, to confirm airflow limitation and COPD Assessment Test (CAT) to quantify symptom burden and predict readmission risk. Next, a patient interview focused on medical history, behavior, and exposure risk. The PDN Team then provides four 15 to 30-minute education sessions, including disease and symptom management, medication review, smoking cessation, and a post-discharge COPD action plan established on evidence-based pharmacological interventions for COPD management.

Outcomes and Impact

The program assessed 558 patients admitted for COPD between August 2021 and October 2022. Within this population, unplanned < 30-day COPD readmissions were reduced by 87.9% in the first year, with COPD readmissions dropping from 26.5% to 3.2% respectively. The program identified a strong correlation (r = 0.904) between early assessment (< 24 hours of admission) and LOS. COPD LOS was reduced by 17.8% (5.17 days to 4.25 days). In addition, the percentage of patients with restrictive or normal spirometry, not consistent with COPD, reduced from 43% to 22% revealing more accurate diagnosing and, thus, better allocation of resources. At baseline, Patients' home regimens were modified 394 times, providing extra support and appropriate post-exacerbation management. The PDN program revealed that proper diagnosis, symptom-based education, and patient-centered discharge planning could result in positive outcomes for the patient and the organization.

_{References: 1. Global Initiative for Chronic Obstructive Lung Disease (2023). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2023 report). https://goldcopd.org/2023-gold-report-2/ 2. Goto, T., Faridi, M. K., Camargo, C. A., & Hasegawa, K. (2018). Time-varying readmission diagnoses during 30 days after hospitalization for COPD exacerbation. Medical Care, 56(8), 673–678. https://doi.org/10.1097/ mlr.0000000000000940 3. MacIntyre, N. R. (2019). Toward reducing COPD hospitalization. Respiratory Care, 65(1), 127–128. https://doi.org/10.4187/respcare.07491 4. Wallace, A. E., Kaila, S., Bayer, V., Shaikh, A., Shinde, M. U., Willey, V. J., Napier, M. B., & Singer, J. R. (2019). Health care resource utilization and exacerbation rates in patients with COPD stratified by disease severity in a commercially insured population. Journal of Managed Care & Specialty Pharmacy, 25(2), 205–217. https://doi.org/10.18553/jmcp.2019.25.2.205}