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REDUCING COPD REHOSPITALIZATIONSPatients with chronic obstructive pulmonary disease (COPD) who are rehospitalized following hospitalization for an exacerbation of COPD are at higher risk of mortality and poor health outcomes. Approximately 20% of patients who are discharged from the hospital following an exacerbation of COPD are readmitted within 30 days. At a home healthcare agency in southeastern United States, 36.4% of patients admitted to the agency with a primary or secondary diagnosis of COPD between August 2018 and January 2019 were rehospitalized within 30 days of admission. A quality improvement project was conducted between January 2019 and July 2019. This project involved

implementation of a COPD self-management care plan packet provided by home healthcare nurses to patients with a primary or secondary diagnosis of COPD. The 30-day rehospitalizations for patients with COPD decreased from 36.4% preinterven-tion to 15.4% postintervention. The number of patients receiving timely follow-up with their provider increased from 79% preintervention to 88% postintervention, and COPD medication reconciliation at admission improved from 79% preintervention to 84% postintervention. The generalizability of these results is limited due to a small sample size and inconsistencies in intervention implementation.

Carmen McGill, DNP, APRN, AGPCNP-BC

Chronic obstructive pulmonary disease (COPD) is a complex and progressive inflammatory airway disease affecting more than 15 million

Americans in the United States. COPD places a significant burden on the healthcare system and affects an individual’s quality of life (Shah et al., 2016). According to the World Health Organiza-tion, the COPD mortality rate is expected to in-crease by more than 30% in the next 10 years, and is expected to be the third leading cause of death by 2030 (Liu et al., 2017). Patients who are rehos-pitalized following a COPD exacerbation are at an increased risk of mortality and poor health outcomes ( Simmering et al., 2016). Nationally, ap-

proximately 20% of patients discharged from the hospital following an acute exacerbation of COPD require rehospitalization within 30 days of dis-charge (Simmering et al.). As a result, the majority of COPD healthcare expenditures are attributed to COPD hospitalizations, at a cost of approximately $13.2 billion annually (Shah et al.; Wang et al., 2017).

Multiple contributing factors lead to COPD rehospitalizations. One modifiable risk factor is ineffective care transitions from hospital to home (Shah et al., 2016). This includes lack of timely patient follow-up with their primary care physi-cian, insufficient patient discharge education,

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March/April 2020 Home Healthcare Now 81

data were collected from February 2019 through June 2019 using the PointCare electronic medical record (EMR). Quantitative data were gathered to compare the percentage of COPD rehospitaliza-tions preintervention and at 5 months postinter-vention.

SettingThis project was implemented at a single branch of a home healthcare agency in southeast United States. The home healthcare agency is a part of a large metropolitan healthcare system, and provides a comprehensive range of services, in-

cluding: skilled nurs-ing, physical therapy, occupational therapy, medical social work, speech therapy, and home healthcare aide services. At the time of the study, the branch had a monthly census averaging between 70 and 80 patients. The nursing staff at the branch include two full-

time registered nurse case managers, four part-time registered nurses, and one full-time licensed practical nurse. Additional staff at the branch in-clude the director, clinical operations manager, two administrative assistants, two physical ther-apists, one occupational therapist, one home healthcare aide, one social worker, and a licensed speech therapist. The home healthcare agency serves patients with Medicare and/or Medicaid who reside in one of two rural counties.

SamplePatients with COPD were referred to the agency following discharge from either a local area hos-pital, skilled nursing facility, or were referred directly from their healthcare provider. The sample for the preintervention data included 33 patients who were admitted to home health skilled nursing services with a primary or sec-ondary diagnosis of COPD between August 1, 2018 and January 26, 2019. Patients in the prein-tervention group included 14 males and 19 females ranging in age from 51 to 96 years old. The intervention sample included 26 patients admitted to the branch between January 27, 2019 and June 30, 2019, who had either a primary

and inaccurate and/or incomplete medication reconciliation (Portillo et al., 2018).

At the home health project site, 36.4% of patients admitted to the agency with a primary or second-ary diagnosis of COPD between August 2018 and January 2019 had an unplanned rehospitalization within 30 days of admission to the agency, which is significantly higher than the 30-day rehospital-ization national benchmark of 20%. A root cause analysis of COPD readmissions identified incon-sistencies in COPD self-management education provided at home health visits, and no standard COPD-specific care plan to assist nurses in pro-viding disease-specific self-management inter-ventions. Home health-care nurses also lacked a systematic method to assess patients’ COPD symptom severity, risk for readmission, or symptom worsening. The evidence supported the incorporation of a structured, disease-specific care plan to re-duce readmissions of patients with COPD. The implementation of individually tailored COPD self-management interventions by home healthcare nurses, including: development of an action plan, teach-back on proper inhaler technique, educa-tion on smoking cessation and lifestyle modifi-cations, with reinforcement of all education at follow-up visits, has been demonstrated in several studies to reduce 30-day rehospitalizations for patients with COPD (Liu et al., 2017; Ospina et al., 2017; Wang et al., 2017).

Project AimsThe overall aim of this quality improvement proj-ect was to implement a COPD self-management care plan packet to decrease 30-day hospital read-missions of patients admitted to skilled nursing services with a diagnosis of COPD. A secondary aim was improvement in COPD symptoms as evi-denced by a reduction in COPD Assessment Test scores from admission to discharge from home healthcare.

MethodsPreintervention data were collected from August 2018 through January 2019, and postintervention

The overall aim of this quality improvement project was to implement a COPD self-management care plan packet to decrease 30-day hospital readmissions of patients admitted to skilled nursing services with a diagnosis of COPD.

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COPD Self-Management Plan. A COPD self-management plan form (Appendix 1, Supplemental Digital Content 1, available at http://links.lww.com/HHN/A120 ) was included in the COPD self-management packet, to be completed by the nurse and patient on admission. The form as-sisted the patient and nurse to identify patient-specific learning needs, such as adherence to COPD medications including oxygen therapy, dietary and lifestyle measures to manage symp-toms, and smoking cessation. The form also addressed an in-home COPD medication reconcil-iation, and whether the patient had a scheduled follow-up with the primary care provider or pul-monologist. The nurse addressed all deficiencies with COPD medications and scheduled follow-up appointments with the patient’s provider. The form was kept in the COPD care plan packet in

or secondary diagnosis of COPD and received skilled nursing services.

InterventionStaff Education. Prior to initiating implementa-tion of the COPD Care Plan materials, nursing staff at the home healthcare agency participated in an educational session on the purpose and use of the intervention provided by the project manager. Of the seven nurses at the agency, five were present at the educational session. The other two nursing staff were educated separately. The educational session lasted approximately 20 minutes. Staff were educated on the COPD Assessment Test, COPD action plan, COPD self-management plan, and educational materials included in the COPD Care Plan Packet. Instruction was also provided on documentation of COPD Assessment Test re-sults and review of COPD care plan packet materi-als in the patients’ narrative note following visits.

The intervention included implementation of a COPD self-management care plan packet, which included a COPD Assessment Test used to as-sess the severity of patient’s COPD symptoms, a COPD action plan, a COPD self-management plan, and educational handouts pertaining to aspects of COPD self-management.

COPD Care PlanCOPD Action Plan. A COPD-specific action plan was included in the care plan packet for the nurse to complete and review with the patient at the admission visit. The action plan included a daily symptom log for patients to track COPD symptoms and oxygen saturation levels. The ac-tion plan assists patients in the management of COPD symptoms and provides patient-directed management of exacerbations. Patient’s symp-toms are categorized in zones based on severity: a green zone indicates the patients’ symptoms are controlled; a yellow zone indicates the pa-tient is experiencing worsening symptoms, and a red zone indicates the symptoms require emer-gent action. If the patient’s symptoms were in the yellow or red zone, the action plan instructed the patient to take appropriate measures depending on symptom severity, including contacting the agency’s 24/7 nurse call line, utilizing their rescue inhalers and/or seeking emergent care. The form was kept in the COPD self-management care plan packet in the patient’s home for daily use, and for review at subsequent nursing visits.

Appendix 1. My Personal Home Healthcare Plan

Admission

1) My goal for the next 1–2 months is:

________________________________________

2) Things I would like to work on to help manage my COPD:

• Taking my Medicine • Monitoring Shortness of Breath• Stop Smoking • Exercise• Eating Healthy

3) Most days I feel that my shortness of breath is:

• Very Slight • Slight • Moderate• Somewhat Severe • Very Severe

4) CAT Score: _____________

Reassessment

CAT Score:

I feel like I am closer to meeting my goal or have met my goal: Yes/No

I would like to continue working on:

______________________________________

Discharge

CAT Score:

I feel like I am closer to meeting my goal or have met my goal:Yes/No

I would like to continue working on:

________________________________________

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March/April 2020 Home Healthcare Now 83

the patient’s home for daily use, and for review at subsequent nursing visits. The nurse docu-mented review of the patient’s self-management plan in the narrative notes within the EMR.

Educational Materials. The educational handouts addressed the following items pertain-ing to self-management of COPD: the purpose and proper technique of inhaler use, oxygen safety, and smoking cessation education. Additional educational handouts covered lifestyle manage-ment of COPD symptoms: identifying/avoiding triggers, using deep breathing exercises, per-forming daily activity as tolerated, eating prop-erly, and identifying/addressing symptoms of anxiety and/or depression. These handouts were kept in the COPD plan packet in the patient’s home for daily use and were to be reviewed with the patient at each nursing visit. Following each visit, the nurses were instructed to document that educational materials were reviewed in the narrative note within the EMR.

COPD Assessment Test. Included in the COPD self-management care plan packet was an 8-item COPD Assessment Test that assesses COPD symptom severity and rehospitalization risk. The a dmitting nurse took this packet to the patient’s first visit. Prior to implementing the COPD self-management care plan, the nurse ad-

ministered the COPD Assessment Test to the pa-tient at the admission visit and documented the patient’s score in their narrative note. The score assisted in determining the patient’s symptom burden and risk of rehospitalization. A follow-up COPD Assessment Test was administered to the patient at the patient’s home health discharge visit.

Measures and Data CollectionThe primary outcome measure was a reduction in the 30-day rehospitalizations of patients admitted to home healthcare with a primary or secondary diagnosis of COPD. The secondary outcome measures were improvement in pa-tient’s score on the COPD Assessment Test from home health admission to discharge, the percent-age of patients having a scheduled follow-up with their primary care provider and/or pulmonolo-gist within 1 week of the admission visit, and completion of a COPD medication reconciliation on home health admission. The process measure that was analyzed to determine adherence to the intervention was the percentage of patients with COPD who received all components of the COPD self-management care plan packet at admission and follow-up nursing visits.

The project director collected deidentified preintervention (August 2018–January 2019) and postintervention (February 2019–June 2019) data through a retrospective chart review of EMR data. Patient demographic variables included: age, gender, admission diagnosis, dates of dis-charge from the hospital, and admission to home healthcare. Additional postintervention data that were collected from the EMR included: the COPD Assessment Test scores at admission and discharge, whether the patient was rehospital-ized within 30 days of admission to home care, whether the patient had documentation of sched-uled follow-up with their primary care provider or pulmonologist at admission, and whether the nurse addressed the presence or lack of appropriate COPD medications in the home on admission.

Ethical ConsiderationsThis project was certified as a quality improve-ment project by the Institutional Review Board at the Medical University of South Carolina. All po-tentially identifiable patient and project site data were removed from data collection and remained

The percentage of 30-day rehospitalizations for patients with COPD decreased from 36.4% in the preintervention period to 15.4% in the postintervention period.

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84 Volume 38 | Number 2 www.homehealthcarenow.org

the number of patients receiving COPD medica-tion reconciliation on admission increased from 79% in the preintervention to 84% postinterven-tion (Figure 2).

A survey was provided to nursing staff near the end of the postintervention period. Although only a limited number of nurses were able to respond to the survey (N = 3), these nurses pro-vided positive feedback about the COPD care plan, expressing its usefulness in providing ongo-ing self-management education interventions to patients with COPD.

DiscussionOverall, this quality improvement project dem-onstrates that there is a slight positive correla-tion between tailored COPD self-management educational interventions provided by home healthcare nurses and reductions in 30-day COPD rehospitalizations. Although the results of this study demonstrated improvement in outcomes, unfortunately there was inconsis-tency in intervention implementation during the postintervention period, which likely affects the

confidential throughout the study. The project team also abided by HIPAA policies and procedures maintained by the agency during implementation of this project.

ResultsThere were 33 eligible patients with COPD included in the pre-intervention sample, and 26 patients in the postintervention sample, with consistent demo-graphic data across both sam-ples. The patients’ ages ranged from 54 to 95 years old (mean = 75) in the preinterven-tion sample, and 55 to 92 years old (mean = 77) in the postinter-vention sample. In the preinter-vention sample, 58% (n = 19) were female and 42% (n = 14) male, compared with 54% (n = 14) female and 46% (n = 12) male in the postintervention sample. However, the number of patients with COPD as their pri-mary diagnosis in the preinter-vention sample was 39% (n = 13), compared with 50% (n = 13) in the post intervention sample.

The percentage of 30-day rehospitalizations for patients with COPD decreased from 36.4% in the preintervention period to 15.4% in the pos-tintervention period. Furthermore, the average percentage of 30-day COPD rehospitalizations was 28% in the preintervention period, com-pared with 19% in the postintervention period (Figure 1). Overall, out of the 26 patients in the postintervention sample, 50% (n = 13) received the intervention materials by their fifth nursing visit. Although 50% (n = 1) of the patients who received the COPD Assessment Test at admis-sion and discharge had an improvement in their score by two or more points, the generalizabil-ity of this result is limited by the fact that only two patients received the questionnaire at both their admission and discharge visits.

The number of patients receiving timely follow-up with their primary care provider and/or pulmonologist within 1 week following hospi-tal discharge increased from 79% preintervention to 88% postintervention (Figure 2). In addition,

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Figure 1. 30-Day COPD Rehospitalizations

Figure 2. Timely Provider Follow-up and COPD Medication Reconciliation

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March/April 2020 Home Healthcare Now 85

nurses have demonstrated to positively impact readmissions in this population (Liu et al., 2017; Ospina et al., 2017; Wang et al., 2017). Prior to this quality improvement project, there was no COPD-specific self-management care plan available at the home healthcare agency. The implementation of a COPD self-management care plan has facili-tated the provision of individually tailored self-management interventions, which coincided with reductions in 30-day COPD readmissions, as well as improvements in COPD medication recon-ciliation and patients receiving timely follow-up with their provider. However, the inconsistency in intervention implementation suggests that additional steps would be needed to promote improved consistency and sustainability of im-plementation, including: incorporation of inter-vention components and/or reminders into the EMR, reductions in nurse-to-patient ratios, and continued buy-in from management and nursing staff.

Carmen McGill, DNP, APRN, AGPCNP-BC, is a Nurse Practitioner, Doctors Making Housecalls Durham, North Carolina.

The author declares no conflicts of interest.

Address for correspondence: Carmen McGill, DNP, APRN, AG-PCNP-BC, Doctors Making Housecalls, 2511 Old Cornwallis Rd, Durham, NC 27713 ([email protected]).

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DOI:10.1097/NHH.0000000000000839

REFERENCESLiu, M., Zhang, Y., Li, D., & Sun, J. (2017). Transitional care interven-

tions to reduce readmission in patients with chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials. Chinese Nursing Research, 4(2), 84-91. doi:10.1016/j.cnre.2017.06.004

Ospina, M. B., Mrklas, K., Deuchar, L., Rowe, B. H., Leigh, R., Bhutani, M., & Stickland, M. K. (2017). A systematic review of the effectiveness of discharge care bundles for patients with COPD. Thorax, 72(1), 31–39. doi:10.1136/tho-raxjnl-2016-208820

Portillo, E. C., Wilcox, A., Seckel, E., Margolis, A., Montgomery, J., Balasubramanian, P., …, Kakumanu, S. (2018). Reducing COPD readmission rates: Using a COPD care service during care transi-tions. Federal Practitioner, 35(11), 30-36.

Shah, T., Press, V. G., Huisingh-Scheetz, M., & White, S. R. (2016). COPD readmissions: Addressing COPD in the era of value-based health care. Chest, 150(4), 916-926. doi:10.1016/j.chest.2016.05.002

Simmering, J. E., Polgreen, L. A., Comellas, A. P., Cavanaugh, J. E., & Polgreen, P. M. (2016). Identifying patients with COPD at high risk of readmission. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 3(4), 729-738. doi:10.15326/jcopdf.3.4.2016.0136

Wang, T., Tan, J. Y., Xiao, L. D., & Deng, R. (2017). Effective-ness of disease-specific self-management education on health outcomes in patients with chronic obstructive pulmonary dis-ease: An updated systematic review and meta-analysis. Patient Education and Counseling, 100(8), 1432-1446. doi:10.1016/j.pec.2017.02.026

generalizability of the results. Overall, only 31% of patients with COPD admitted to the agency received the intervention materials at their ad-mission visits as was recommended. However, 42% of patients received the intervention materi-als by their fifth skilled nursing visit. Several contextual factors likely contributed to these inconsistencies in implementation, including: the inability to incorporate intervention materi-als and/or reminders into the EMR, shortage of nursing staff during implementation, utilization of staff from outside branches, change in man-agement during project implementation, and the project mentor being located at an outside branch within the agency. However, despite these inconsistencies in implementation, a sur-vey presented to nursing staff near the end of the postintervention period concluded that the intervention materials were perceived as benefi-cial to improving self-management education for patients with COPD. Thus, additional steps would need to be taken in order to improve the consistency of COPD self-management interven-tion implementation in the agency, which could result in significantly reduced rehospitalizations in patients with COPD.

LimitationsThere are several significant limitations to this study’s generalizability, including the small sample size in both the preintervention and post intervention periods, along with the short project time frame. The sample size during the posti ntervention period was much smaller than anti cipated, with only 26 patients in the post-intervention sample, compared with 33 patients in the preintervention sample. Thus, the data were prone to significant volatility from month-to-month. Additional limiting factors include the inconsistency in intervention implementation in the postintervention period, which may limit the association between the intervention and the study outcomes.

ConclusionWith the significant burden that COPD readmis-sions place on both the healthcare system and the patients affected, evidence-based interven-tions are needed to improve outcomes and re-duce hospital readmissions in this population. Individually tailored COPD self-management in-terventions conducted by home healthcare

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