Mr Jones is a 56-year-old male who has had 11 emergency department visits and five hospital admissions in the last 12 months, all of which are attributed to chronic obstructive pulmonary disease (COPD) exacerbations. He has been diagnosed with COPD—Gold Stage III. At each visit to the emergency department, Mr Jones received standard pharmacological treatment and was discharged to home with no additional services. The length of stay for each hospital admission was 1 day. At each discharge, he was provided with prescriptions for antibiotics and bronchodilators, and given a pamphlet on “How to Manage COPD.”
This patient scenario occurs frequently at hospitals across the United States. In fact, according to the National Heart, Lung, and Blood Institute, COPD is the fourth leading cause of hospital readmissions in the country.1,2 Nearly 23% of COPD patients are readmitted within 30 days of discharge, a significant multibillion-dollar financial burden to hospitals.1,2 Much research has been focused on the etiology of COPD exacerbations, but relatively little research is available on the nonphysiological reasons that these readmissions occur. Standard case management practice includes nurse-directed disease management programs such as assessing and monitoring the disease, pharmaceutical management, reducing risk factors, and controlling exacerbations.1 Health care teams are not maximizing appropriate resources to treat this patient population. We focus primarily on the disease rather than the person and fail to use the expertise of respiratory therapists in the discharge planning process.
I argue first that COPD disease management programs must be developed by teams that include respiratory therapists with advanced cardiopulmonary training and that they must be individualized based on the patient’s level of health literacy. Second, licensed respiratory therapists are uniquely poised to work with this population, but the majority of US hospitals require either an RN or SW degree when they employ case managers.1 Third, patients must be seen as holistic entities, not as disease processes.
DEVELOPING A SAFE, APPROPRIATE DISCHARGE PLAN
The most critical components to transitioning a COPD patient from acute to post-acute care settings are the completion of a comprehensive, individualized assessment, evaluating the patient’s true needs, and implementation of an appropriate discharge plan directed at reducing the potential for readmissions.1 Sound case management requires a holistic approach by looking at the “whole person,” including internal and external factors. Every facet of a person’s life has the potential to wreak havoc on their ability to reduce COPD exacerbations and optimize wellness. Additionally, case managers must determine which problems are actual “barriers to discharge” and which can be addressed in the post-acute care setting. So what should case managers look at and how can the expertise and advanced cardiopulmonary training of the respiratory therapist be of benefit to our COPD patients?
Living Situation—Who, What, Where? How? A patient’s living situation is critical to the case management process. Where does your patient live? With whom do they live? What do they live in and what type of structure is it? How do they enter and leave their home? These and many more answers allow the case manager to determine what services may be appropriate and if they can be provided as the patient transitions to home or a facility.3,4 Respiratory therapists with home health care backgrounds have extensive insight into these concerns.
Caregiver Support. Often, caregivers are just as debilitated as patients. Frequently, family members are unwilling or unable to provide care for the patient, regardless of the short- or long-term nature of the needs. It is critical to determine if caregivers are appropriate and willing to provide for the needs of a COPD patient, especially given the complexity of treatment regimens.
Financial Issues. Financing health care and navigating the maze of payors, plans, and reimbursements can be overwhelming for most patients. This is especially true for patients with cognitive or functional impairments that limit or prevent self-advocacy. Many patients are resistant to applying for disability, Medicaid, and financial assistance for a multitude of reasons. Case managers must be not only knowledgeable about what resources exist for individual patients, but also adept at breaking the barriers of “application resistance” from patients and their families.
Spiritual and Cultural Beliefs. Cultural competency is a goal for all members of the health care team because spiritual and cultural beliefs of the patient and their family impact treatment decisions and adherence.5 We must be mindful that our patients have their own core belief and value systems that may not coincide with ours, but are equally deserving of our respect and understanding.
Advanced Care Directives and Palliative Care. Very often, patients with COPD do not grasp the unpredictable or progressive nature of the disease. Additionally, the illness itself as well as medications used to treat the illness can result in diminished capacity. Discussions regarding goals of care should be initiated at diagnosis and maintained along the continuum.3 Too often, physicians are reluctant to refer patients for palliative care consults; case managers must advocate that these discussions are not about “dying” but rather quality of life. Patients need to receive education regarding advanced care planning and appointment of health care powers of attorney. It is imperative that patients and families have time and opportunities to discuss details of the patient’s wishes. Respiratory therapists should be part of these conversations due to their advanced training in disease trajectory, treatment options, and comfort care.
Transportation and Medical Appointments. Frequently, patients do not have reliable, affordable transportation.5 COPD patients need close affiliations with primary care providers (PCPs) and other medical specialists. How does your patient get to medical appointments or pick up their medications? Expectations that patients will keep appointments are unrealistic if transportation resources are not available. Making patients and caregivers aware of resources available to them can help make the treatment plan successful.
Nutrition. Most COPD patients have therapeutic dietary needs. Many patients are unable to prepare their own meals or even get to the grocery store. Many stop eating as the disease progresses. It is imperative that case managers address this issue with patients and caregivers to ensure optimal nutrition.5 Respiratory therapists have advanced expertise in the role nutrition plays in the disease process as well as teaching and promoting therapeutic diets for COPD.
Risk Factors. Smoking is the primary risk factor for COPD.6 However, many of our patients may be affected by other risk factors such as occupational exposure to particulate matter, pollution, age, gender, history of childhood respiratory infections, and socioeconomic status.5,7 Respiratory therapists are experts in the evaluation of these risk factors as well as the development of smoking cessation and clean air programs.
Health Literacy. A standard practice of the disease management model is to provide patients with a written, “one size fits all” booklet educating them on managing COPD.5 What is your patient’s level of health literacy and can they even read? Individualizing education for patients with COPD based on their level of health literacy is necessary if we expect to optimize adherence and reduce exacerbations, ED visits, and hospital readmissions.
Functional and Cognitive Limitations. Patients with COPD generally have multiple comorbid conditions.7,8 Additionally, many have limitations that prevent them from adhering to the medical regimen: cognitive or memory deficits; visual, hearing, or speech impairments; and functional limitations that render them unable to manage activities of daily living independently, as well as placing the patient at high risk for falls. Discharging a COPD patient from the hospital to a post-acute care setting without evaluating these areas and addressing specific needs is simply not good practice. Input from members of the health care team, including respiratory therapists, speech therapists, physical therapists, occupational therapists, and psychologists, is critical to this phase of the evaluation.
Mental Health and Substance Abuse. Patients with progressive, debilitating disease processes such as COPD frequently suffer from minor to major depression, other mental health diagnoses, or substance abuse.7 Connecting patients to resources to address these issues can be a component of the case management process if the patient is amenable.
Medications. Approximately 50% of COPD patients are not compliant with medication therapy. Studies show that patients take less than 50% of the medications prescribed.5 There are multiple reasons for this low level of compliance: financial; low health literacy4; cognitive, memory, and reasoning deficits; and difficulty administering the medications.5 Health care teams need to know why patients are noncompliant and implement interventions wherever possible. Respiratory therapists have advanced pharmacological training and the expertise to evaluate, educate, and work with medication compliance issues.
Post-Acute Care Services. Available resources for COPD patients vary from city to county to state. Resources exist for medication assistance, transportation, respite care, volunteer caregivers, ostomy supplies, nutritional assistance, housing, and so much more. When patients are homebound, we need to make sure they are referred for home health services appropriate for their needs, including a COPD management program. When COPD patients are not homebound, determine if they meet criteria for an outpatient pulmonary rehabilitation program. Each appropriate service you can connect your patient to is potentially one less emergency department visit or readmission to the hospital.
TRANSITION FROM ACUTE TO POST-ACUTE CARE
In the example of our COPD patient, Mr Jones, we discovered that he has significant post-acute care needs. He lives at home alone in a second-floor walk-up apartment and experiences significant shortness of breath going up and down the stairs. He is homebound due to the difficulty of getting in and out of his apartment. He states he is unable to take showers because he is afraid he will fall in the shower and therefore has been “washing up” at the sink. On the day of discharge, Mr Jones has a room air SpO2 of 86% while awake at rest. He is insured but never purchased a Part D program. He obtains his medications at a pharmacy offering $4 generics but is not able to afford name brand drugs, because his disability income is only $800 per month. He has been buying his brand name drugs sporadically and hence not taking them as prescribed. He has lost about 20 pounds over the last year and does not eat a prescribed COPD diet because he is unable to get to the grocery store very often. Additionally, he reports shortness of breath while eating, which makes him less inclined to do so.
Mr Jones has no local family support, because his children, from whom he is estranged, live out of state, and further, he states, he doesn’t really have any friends. He does have a church family, although he has not been to church in many months. He has a driver’s license but no vehicle because he could not afford the insurance. Mr Jones admits to being depressed but states, “It just goes with the territory,” and that he’s never spoken to anyone about it. He has a primary care provider, but states that whenever he calls for an appointment, the waiting time is several days and that the office is 15 miles from his home and he can’t find anyone to take him to the appointment. Finally, Mr Jones states that he stopped going to school in the sixth grade and cannot read very well. So what steps did the respiratory therapist case manager take?
- Referred Mr Jones for home health services, which are covered at 100% by Medicare to include an RN, physical therapist, occupational therapist, dietician, home health aide, and social worker who can connect him to community resources as well as assist him in completing a Medicaid application. If approved for Medicaid, he may be covered for special pharmacy assistance and Medicare D premiums, financial assistance to transfer to an assisted living facility, and transportation resources.
- Determined that Mr Jones is eligible for pharmacy manufacturer benefits for each of his brand name drugs and initiated applications on behalf of patient. He will receive these medications free of charge.
- With his permission, contacted pastor of Mr Jones’ church to arrange visits to the patient at home. Requested church members to provide intermittent volunteer services, such as meals and providing care as well as transportation.
- Ordered home oxygen for Mr Jones. Requested evaluation for and dispensing of a lightweight portable oxygen system and conserving device. Requested clinical respiratory therapist visits from a durable medical equipment company to train and educate patient. Assistive and ambulatory devices will be determined by physical therapy/occupational therapy in the home.
- Provided Mr Jones with contact information for COPD support group, which is two miles from his home.
- Requested acute care respiratory therapist to provide bedside teaching of medications and devices, COPD disease process, COPD diet recommendations, and breathing exercises.
- Prior to discharge, Mr Jones had a palliative care consult to discuss goals of care. The consultant reviewed advanced directive forms with him, including health care power of attorney, which he completed and had notarized in the hospital.
Licensed, qualified respiratory therapists should be integral participants in the care of patients with COPD throughout the continuum of care. They are advanced cardiopulmonary specialists who are specifically trained to deal with the COPD patient population in both the acute and postacute settings, and can provide cost-effective services to patients. Respiratory therapists are trained to order home oxygen, noninvasive ventilation, and respiratory medication devices, and have the expertise to evaluate and make recommendations as to which system and prescribed settings are most appropriate. They are highly skilled in pharmacology and medication administration and delivery. They are the most competent and appropriate members of the health care team to develop and deliver education and training to patients with COPD and their families.
Respiratory therapists are trained to view patients from a holistic purview, rather than as disease processes. Respiratory therapists are essential to the case-management process and profession and should be utilized as core members of the COPD health care team. I strongly urge hospitals nationwide to open their doors to respiratory therapists as the most appropriate case managers for COPD patient populations. As significant changes occur within the reimbursement system, we must look beyond the disease and also focus our attention on the individuals we treat. As health care systems find themselves more and more accountable along the continuum of care, it behooves us to find new ways of dealing with old problems.
Stacey Ray, RRT, RCP, BA, CCM, is a board-certified case manager who was the first case manager hired into clinical care management at UNC Hospitals in Chapel Hill, NC, 3 years ago. She began with the pulmonology service, transitioned to the most complex cases in the hospital, and currently manages patients on the cardiology and heart failure medicine services. She has worked as a registered respiratory therapist for almost 20 years in acute care, home care, and management. For further information, contact [email protected]
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