COPD Care: Basics to Partnerships

Chronic Obstructive Pulmonary Disease (COPD) is a debilitating disease whose impact on our nation’s health and health care system cannot be understated in terms of lives affected or cost.

COPD affects 30 million Americans nationwide. According to the COPD Foundation, it affects 6.5 percent of the population in North Carolina alone. While these numbers are alarming, the cost burden of this disease is severe, with estimated direct costs at $32 billion and indirect costs at $20.4 billion, according to the Global Initiative for Chronic Obstructive Lung Disease.

As providers across the spectrum of health care look to reduce costs and improve patient outcomes, homecare can play an integral role by reducing hospital readmissions and improving a patient’s quality of life.

There are some simple strategies that all homecare agencies can incorporate into their care planning to improve COPD patients’ outcomes. Well Care Home Health looked to partner with innovative and forward-thinking organizations to further drive down costs and maximize quality of life for patients.

Front-loading visits, patient education, proper medication management, and additional therapies and outreach make a difference in COPD care.

The Basics

Home health nurses should focus on front-loading their COPD patient visits. Set a goal for three visits within the first seven days of the patient’s admission to home health service and an admission visit made in the patient’s home within 48 hours of discharge from the hospital; then gradually reduce visits as the patient becomes more stable.

It is not enough to just make the visit; nurses who are making these visits must be tuned in to changes in the patient’s condition over time. This requires astute assessment, detailed documentation and continuity of care to ensure that subtle changes (such as new lower extremity swelling, increased shortness of breath or altered level of consciousness) can be detected. Even picking up these small changes in the patient’s condition isn’t enough; changes need to be relayed to the attending physician in a meaningful way so that the correct interventions can be put into place to avoid a hospitalization.

We teach physician reporting using the SBAR method (Situation, Background, Assessment, Recommendation). If you do not provide a recommendation to the MD, you may end up with a physician telling you to send the patient to the ER for evaluation. There is no reason homecare agencies can’t coordinate oral or IV steroids, oral or IV antibiotics, outpatient chest x-rays or any other treatments in the home to avoid an unnecessary trip to the hospital for your patient.

Patient Education Vital in Care Process

Education is also vital in this process so that patients can effectively do their part in the care process. Focus on teaching recognition of an impending problem and effective prevention and recovery tactics.

1 Signs and symptoms to teach the patient to monitor for include wheezing or coughing, change in mucus characteristics, swelling in the feet or ankles or fever/chills. Explain these within the first visit to the home, and patients should know to call their nurse as soon as symptoms arise.

2 Prevention of future exacerbations is essential to keeping the patient home throughout and even after your episode of care is over. Some items to focus on with patients are the importance of hand hygiene, avoiding crowded areas during peak cold and flu seasons, and how the weather or environment impacts their respiratory status. Additionally, nurses should reinforce influenza and pneumonia vaccines, encourage diligent follow-up with the patient’s primary care physician, and recommend a pulmonary specialist if the patient’s primary care physician (PCP) is in agreement.

Medication Tips

Proper medication management is an imperative part of the COPD patient’s life. One of the biggest contributors to readmission rates is medication adherence problems, whether it’s a lack of knowledge or the inability to afford medicine.

Home health care clinicians have a duty to help COPD patients understand their medications and ensure they have access to them on the first admission visit. When reviewing medications with all patients, you should ensure that they are actually able to fill the prescriptions. Using a patient-provided list or a discharge list from an inpatient facility may provide useful insight into what medications the patient should be taking, but it will not tell you what the patient actually has access to.

COPD dosing schedules can be complicated, especially when it comes to oral steroids and some common antibiotics that have to be taken more than once per day. This can be confusing and overwhelming to elderly and recovering patients, so the admission visit and the initial follow-up visits should focus on strategies to simplify medication regimens and validation that the correct regimen is being followed.

Inhalers can be another point of confusion for COPD patients, that nurses may be overlooking. First, is the patient even using their inhaler correctly? Remember, it’s not enough to simply ask the patient if he or she knows how to use the inhaler (you wouldn’t check someone off on changing a wound dressing that way); instead, validate the patient’s competency by observing them using the inhaler. Second, ensure that patients know the difference between their long-acting and short-acting inhalers and that they are aware of when to use them. Patients should not use their longer-acting inhalers in response to an acute exacerbation, as they will not see the immediate results.

Three Types of Therapy

Physical therapists, occupational and speech therapists all play a crucial role in the recovery of COPD patients, including their ability to help restore patients to their prior level of functioning before the disease.

1 Physical therapists can address conditioning of COPD patients, which increases their risk of injury from falls. Increasing activity effectively helps with endurance and improves a patient’s ability to function independently.

2 Occupational therapists help COPD patients with adaptive techniques so they may more safely complete activities of daily living (ADLs). An OT understands and can guide the patient on individualized energy conservation techniques that can improve overall quality of life.

3 Speech therapists do more than assist patients with a swallowing defect. They also create cognitive techniques to help patients who may be struggling with complex medication schedules or routines.

Well Care’s goal is to become a comprehensive post-acute care provider. Headquartered in Wilmington, North Carolina, the agency launched in 1987 with seven employees providing homecare services in New Hanover County. Today, the company is an integrated home health and homecare agency servicing 42 North Carolina counties, with regional offices in Raleigh, Wilmington and Mocksville, and additional locations. The agency employs over 800 people. Innovative Partnerships

Innovative Partnerships

• Health Recovery Solutions (HRS)—Using HRS, Well Care Home Health is expanding its telehealth program beyond traditional diagnoses to include COPD patients. This will allow for video visits with patients when they trigger symptom alerts through the automated system. It will also allow for closer monitoring of patients, while minimizing the number of nursing visits later, to decrease utilization and cost without sacrificing quality.
   
• Cipher Health—Cipher Health specializes in patient outreach. Automated calls address a variety of questions ranging from the patient’s condition to the customer experience. Alerts are then sent to clinical teams if the patient identifies an issue. Patients can be reached in real time, without investing significant resources to call every individual patient. In four months since Well Care launched the program, Well Care reached more than 4,100 patients at an engagement rate of 90 percent.
   
• Pharmacy at Home—In the Raleigh market, a pilot with C3 pharmacy is in the beginning stages. Pharmacy technicians make visits to patients’ homes the same day as a Start or Resumption of Care, to review and reconcile the patients’ medications in collaboration with a C3 pharmacist. This partnership will look to capitalize on that expertise for Well Care’s patients.