Purpose: The goal of this program is to improve the quality of life in COPD patients. An outpatient resource center provides post-discharge follow-up in order to facilitate continuum of care.

Background: Frequent readmissions are common in the COPD patient population and have become a focus of the CMS value based measures. Research has shown a 7.1% 30-day readmission rate for a principal diagnosis of COPD and a 20.5% for all-cause 30-day readmission. Patients often do not have a resource which guides them through the continuum of care from inpatient to home. Knowledge deficits regarding medication administration and regimen can lead to poor-compliance and therefore worse outcomes. Understanding the disease process and progression is key if patients are to receive the maximum benefit from their medications. Many of these patients suffer from more than one chronic medical condition which leads to complicated medication regimens. The GOLD recommendation for post hospital discharge to lessen exacerbation-related readmissions is an early follow-up process. However, upon discharge, many of these patients are not back to their baseline and often are unclear about their treatment regimen. According to the Institute for Safe Medication Practices (ISMP), 94% of patients with COPD and asthma use their inhalers incorrectly which can lead to a reduction of efficacy and poor outcomes. Intensive outpatient monitoring, evaluation, and education are needed to prevent readmissions. COPD patients often do not have a resource center that follows up within 1 week of discharge to evaluate their condition, provide intervention, and guide them through the continuum of care from inpatient to outpatient status.

Methods: A Lung Health Outpatient Resource Center was assembled using the resources of a multidisciplinary team. The team facilitates to progress patients through the continuum of care with the goal of improving the quality of life and decrease readmissions. Prevention strategies are initiated after an exacerbation; both pharmacologic and non-pharmacologic interventions are used to complement the individual’s treatment goals. The multi-disciplinary team was headed by the Respiratory Department and included: a nurse practitioner (ARNP), respiratory therapist (RT), registered nurse (RN), social work (SW), physicians, and pharmacy. Prior to a COPD patient discharge, an appointment is scheduled at the Lung Health Outpatient Resource Center. During the appointment, the ARNP, RT, and RN evaluate the patient and provides treatment as needed. Education about the COPD disease process and self-management are provided by the multidisciplinary team. The team helps identify and reduce exposure to internal and external risk factors. If further interventions are indicated, the patient’s pulmonologist is contacted for further treatment options.

Results: The program started in June of 2017 and data was collected until February of 2018, (9 months). A total of 56 patients were seen in the outpatient clinic and out of the 56, 5 were readmitted for all cause diagnosis and zero cases were admitted for COPD exacerbation.

Conclusion: A multidisciplinary Lung Health Outpatient Resource Center made a significant impact in the reduction of COPD readmission rates.

Publication Date


Presented At:

13th Annual BHSF Research Conference

Content Type

Poster Presentation

Additional Authors:

Maureen Lintner BSRT, RRT

Jose Morales BSRT, RRT

Margarita Pallares ARNP, MSN

Maribel Matos ARNP, MSN

Open Access

Available to all.