Effects of a post-discharge COPD clinic on readmissions among veterans with COPD exacerbations
Methods: The Jesse Brown Veterans Affairs Hospital in Chicago, Illinois, implemented a quality improvement (QI) program to reduce the number of avoidable readmissions in patients hospitalized with COPD exacerbations (Recovering Obstructive Lung Disease [ROLD] clinic). The ROLD clinic consists of 3 visits over 4 weeks and features an integrated care model with pulmonary and palliative care physicians, nurses, nurse practitioners, social workers, pharmacists and: (1) a standardized post-discharge clinical evaluation, including medication reconciliation; (2) optimization of medical therapy for COPD; (3) spirometry and O2 evaluation; (4) literacy-appropriate education, including use of medications and inhalers; (5) smoking cessation advice and referral; (6) referrals to pulmonary rehabilitation, social work, and other follow up as needed; and (7) coordination with primary healthcare provider.
Results: Of 127 patients referred to the ROLD program clinic over 18 months, 60% attended at least 1 appointment. Among patients who attended at least 1 post-discharge ROLD program appointment, the 30-day readmissions rate was 12%. Compared to the 12 months prior to the ROLD clinic, the 30-day all-cause readmission rate for all patients hospitalized with COPD exacerbations dropped 5% (from 19% to 14%).
Conclusion: An intensive interdisciplinary post-discharge COPD clinic greatly reduces the need for readmissions among veterans. Whether less resource intensive approaches are also effective deserves study.
Learning Areas:Chronic disease management and prevention
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs
Provision of health care to the public
Describe clinical characteristics of patients recently hospitalized for COPD exacerbations Describe readmission rates before and after implementation of a post-discharge COPD clinic
Keyword(s): Patient-Centered Care, Chronic Disease Management and Care
Qualified on the content I am responsible for because: I currently serve as the Clinical and Research Program Manager for the Breathe Chicago CenterÂ© and the Population Health Sciences Program at the University of Illinois at Chicago. My research interests involve health services research dedicated to improving health care delivery and patient outcomes across the health system. I also currently practice at the Jesse Brown Veterans Administration in the Recovering Obstructive Lung Disease Clinic, a post-discharge, multi-disciplinary care coordination clinic for COPD patients.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.