STEP plan shows promise for care management
by Jean Rommes

Chronic obstructive pulmonary disease (COPD) is a devious disease.

I’ve been living with it for more than three decades and will be living with it for the rest of my life.

When it comes to COPD, I have more good days than bad, which is not true for many of the estimated 24 million Americans living with this progressive lung disease. Everyday activities for them can be a struggle—getting groceries, attending a grandchild’s soccer game, even walking from one room to the next in their own home. Simple actions so many healthy people take for granted can be daunting for COPD patients, especially those who constantly require oxygen delivery systems.

COPD makes life more complicated—it requires more planning. Without proper planning, the risk of being hospitalized—maybe ending up in the ICU or on a ventilator—is greater. COPD exacerbations not only account for the bulk of hospital admissions, they also make up more than half of the cost of COPD services.

Medicare has hit more than half of hospitals nationwide with readmission penalties, to the tune of $528 million. Strides are being made to reduce readmissions (decreasing them an average of 8 percent nationally since 2010), but they’re not enough. Patients are either not being given clear information on how to manage their conditions outside of the hospital, or they don’t follow through on the information they’re given.

To better serve COPD patients, a group of pulmonary physicians consulted with Nonin Medical Inc. to help create a new COPD STEP (Seamless Transition and Exacerbation Prevention) Plan. The goal is to give doctors, homecare providers seeking to help their referral-source hospitals, and patients the tools they need to better manage the disease outside of the hospital. The STEP Plan focuses on six areas of patient care:

1. Cross-Continuum of Care

Dr. Brian Tiep is the director of pulmonary rehabilitation at City of Hope Medical Center in Duarte, California, and medical director of the Respiratory Disease Management Institute in Monrovia, Calif. He has treated COPD patients for more than 40 years, and his program has a 4 percent admission rate for COPD exacerbations. Tiep’s patient-centered, cross-continuum of care approach is one of the main elements incorporated into the new STEP Plan.

“Hospitalizations are preventable by good self management in partnership with the health care provider that includes a rapid action plan—early anticipatory detection and rapid response. Either the patient waits too long after the start of an exacerbation before seeking treatment, or there’s not enough training or health care follow-up once they go home,” says Tiep. “We have to change what we do for these patients.”

Since home respiratory care visits are not typically provided, this lack of professional post-discharge follow-up care can lead to readmissions. Tiep says the STEP program’s comprehensive team approach can better help patients manage both the acute flare-ups and chronic aspects of the disease.

2. Patient-Centered Care

Most current models of outpatient and at-home care rely heavily on medications and devices. These models miss a vital part—the patient’s lifestyle, level of understanding, commitment and personal involvement in treatment.

Dr. Brian Carlin is a pulmonologist in Pittsburgh, Pennsylvania, and the chairperson of the National Lung Health Education Program (NLHEP). He has assisted with the development of two pilot projects that reduced COPD 30-day readmissions from an average of 23 percent, to 10 percent to 15 percent following the intervention. Carlin says patient-centered care was a major factor in reducing readmissions and why it’s at the core of the COPD STEP Plan he co-created.

“One of the goals of these readmission reduction programs, in which I collaborated, is to target and treat patients based on what nurses and respiratory therapists see happening in the patients’ homes. Since these care professionals are on the front lines, they can help spot and address issues in a real-time manner. They can also see that the patient is making appropriate changes. Through the programs, we saw caregivers really get to know their patients, both in and out of the hospital. Through those relationships, they were able to limit the number of patient treatment steps that often fall through the cracks, thus limiting the number of exacerbations and, over time, also reducing readmissions.”

3. Active Lifestyle

Exercise can’t reverse COPD, but it has long been the key to successful disease management. When I first took control of my health, I went on a diabetic diet and started an exercise program while using oxygen continuously—18 months later, I had lost more than 100 pounds and was off oxygen completely. Since then, my exercise regime has stayed pretty steady, but too many COPD patients don’t think they can, or even attempt to exercise.

“It’s a vicious cycle,” Tiep says. “You’re short of breath for an activity, so you stop doing that activity. You then become deconditioned, which increases your breathlessness when you do try to exert. This takes the patient down the deconditioning Chronic obstructive pulmonary disease (COPD) is a devious disease. I’ve been living with it for more than three decades and will be living with it for the rest of my life. ladder. In order to live a more quality life they will need to climb back up the conditioning ladder.”

4. Patient Training

Unfortunately, studies have shown that when patients go home, they likely don’t remember much of the information they were provided during the discharge process.

“It’s imperative that they learn on their own outside of the hospital about how to participate in their own care,” Carlin says.

Tiep agrees, “Patients don’t learn how to do it once, then do it the rest of their lives. Education, training, reinforcement must occur over the life of the patient; it is central to what we do.”

Tiep and Carlin recommend giving patients a checklist of responsibilities and daily activities, which are then monitored, reviewed and reinforced by their respective at-home caregivers and primary physicians.

5. Proper Equipment

The new COPD STEP Plan also spotlights the need for proper equipment and proper training for how to use it. “Unlike patients with other health issues, COPD patients aren’t able to go home, simply take their pills, and hopefully get better,” stresses Carlin. “Most of our therapies are inhaled therapies and should be tailored to the individual patient’s specific needs. We have to address how these patients are monitoring their condition at home, and teach them which types of inhaled medications are best for their specific needs and how to properly use them.”

However, Tiep points out that reimbursement structures force some homecare providers to source less expensive equipment and/or equipment requiring fewer home service calls. While equipment alone won’t reduce readmissions, adequate equipment can help patients live an active life and confidently manage their disease.

6. Rapid Action Plan

For COPD patients undergoing an exacerbation, “time is tissue.” An exacerbation is a destructive process and can contribute to disease progression. If exacerbations are caught early and treated rapidly, hospitalization and re-hospitalization may be avoided.

“Think of an exacerbation as a forest fire. If you catch it when it’s just starting, you can stomp it out. If you catch it five minutes later, you can put it out with a garden hose. Any later than that, it takes a massive force of firefighters and can destroy a forest,” says Tiep. “We want to train our patients on how to recognize their symptoms early, start their treatment plan and, in the process, avoid having to be hospitalized.”

Ultimately, by following the STEP Plan, Carlin and Tiep hope more COPD patients will be able to take charge of their health and live better lives.