Title:COPD Readmissions Reduction Program: Barriers and Challenges Post-Discharge

Title:COPD Readmissions Reduction Program: Barriers and Challenges Post-Discharge

Presenting Author:Samantha Espinosa1

Co Authors:Tina Shah2, Edward Kim2, Steven White2, Valerie Press2

1, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States
2, University of Chicago Medicine, Chicago, Illinois, United States

Background:Chronic Obstructive Pulmonary Disease (COPD) is the 3rd leading cause of hospital readmissions and cause of death in the US. The Center for Medicare and Medicaid Services recently instituted financial penalties for excess readmissions within 30 days after acute exacerbations of COPD (AECOPD). Interventions to reduce readmissions are needed and there is currently a dearth of sufficient evidence on effective methods. The University of Chicago Medicine (UCM) has an inter-professional team that implemented a readmissions reduction program (RRP). As part of the team’s program, 48 hour post-discharge nurse phone calls are made to identify barriers to ongoing health care needs, including the patient’s symptoms since discharge, their ability to take medication doses, and their plans for transportation to a one to two week follow-up appointment with the RRP’s nurse in the pulmonology clinic. The objective of this study was to quantify key responses from the RRP nurse’s phone call survey to identify barriers to care after discharge which may contribute to readmission rates.

Methods:This is a quantitative sub-study of the observational survey from a RRP intervention at UCM of AECOPD patients admitted between January 1st2015 and May 11th2016. Patients who received care from the RRP’s inter-professional teams during admission had a nurse call them 48-hours after discharge to identify potential barriers to care including issues with discharge communication, medications, transportation to the follow-up appointment, and on-going symptoms. The percentages reported for survey responses are relative to the number of responses for each specific question, rather than the total number of included surveys as some surveys did not have answers for every question.

Results:Among 630 total encounters, 81% (n=509) resulted in 48-hr post-discharge phone call attempts. Of these attempts, 66% (n=334) were to unique patients with their first encounter, and 63% (n=211) of those attempts led to completion of the phone survey by the patient (58%, n=195) or a proxy (5%, n=16). Discharge communication was not reported to be a significant barrier as the vast majority (96%, n=201) of patients reported understanding their discharge summary and instructions. The majority of patients (78%, n=162) reported filling their prescriptions or were not prescribed new medications, with the most commonly unfilled medication being the rescue inhaler. Most patients also reported taking all of their medications doses (86%, n=177). Among the reasons for missing at least one dose (n=29), neither forgetting (n=6), cost (n=0), availability (n=1), nor side effects (n=0) explained most of the missed doses. With regard to transportation to the one week follow-up appointment, about one-quarter planned to arrive on their own using a car, taxi, or bus (26%, n=51). Almost 10% (n=18) planned on coming but did not have a planned method of transportation. Over half of the patients (61.2%, n=120) were relying on someone else, such as PACE medivan, friend, or family member, to provide transportation. Lastly, some patients were suffering from COPD-related symptoms at least 48 hours post-discharge. Almost 12% (n=25) of patients reported having more breathlessness than at discharge. This was predictive of readmission (p=0.01). Nearly 15% (n=30) reported significant weakness impeding routine activities. Less than a quarter of the patients (21.2%, n=44) felt their activity level was either back to normal or they were more active than at discharge.

Conclusions:This study quantified survey responses from a COPD readmissions reduction program, delineating four categories of challenges to patients utilizing healthcare resources and maintaining their health. Discharge communication was reported to be the least significant barrier for patients, while transportation to the follow-up appointment, missing medication doses, and suffering from COPD-related symptoms were more commonly faced challenges. One-fifth of patients reported not filling their prescriptions, with rescue inhalers being the most frequently unfilled. Further clarification in the survey is needed to explain why some patients reported missing doses. The presence of these challenges provides areas where UCM’s COPD Readmissions Reduction Program may consider focusing its efforts on subsequent Plan-Do-Study-Act cycles. Next steps involve further investigation to determine if any of these identified factors or simply successfully contacting patients by phone are correlated to patient attendance for the follow-up appointment in the pulmonary clinic, and ultimately readmission rates. This further study will provide insight into specific interventions to reduce COPD-related readmissions which may be replicated in other hospitals.