Best Practices for Managing Care Transitions for Patients with COPD

Wendy Martinson, MSN, RN

C0-Chair:  Sara Szafranski, BSN, RN

C0-Chair:  Lori Ryan, MSW

The Dream Team of Farmington Valley

• Home Care, Skilled Nursing, VA
• Acute Rehab, Assisted Living
• Pharmacies, Providers, DME
• CCCI, UConn Staff, Interns, Students

Issues of Managing Care

• Accurate medication reconciliation
• Communication
• Availability of 7-day follow up appts.
• Lack of standardized education
• Cost of inhalers

Major Barriers

• Time to educate staff / Staff "buy in"
• Cost of medications
• Transportation
• Appropriate disposition
• Patients mislabeled with COPD

Best Practices

• COPD Zones and Inhaler education
• Spacers for patients with MDI
• 7-day follow up appt before discharge
• Multidisciplinary team approach
• Monthly readmission conference

Inhaler Education

Problems with Inhaler Use

Inhaler Education Continued

• 2014 mandatory "hands-on" education
• Respiratory Therapists and MDIs
• Spacers given to all patients with MDIs

UConn COPD Sub-Committees

Target Sub-Committee

• Patient identification
• Sputum cultures
• 7-day follow up
• Spirometry / PFTs

Transition Sub-Committee

• Oxygen testing/ordering
• Discharge phone calls
• Use of transition codes
• Inhaler education
• Dream Team/COPD Champions

Treatment Sub-Committee

• Admission order sets
• Follow GOLD guidelines
• When to involve pulmonary
• Discharge order sets

Identifying COPD Patients

• Admission list
• Daily report of IV & PO steroids
• COPD email distribution

Lessons Learned

• Share data and initatives
• Share educational opportunities
• Email communication works

When to get pulmonary involved

• Intermediate Care Admission (non-invasive)
• Exacerbation (invasive)
• Exacerbation admission lasting >3 days
• Exacerbation readmission within 30 days

How does the Dream Team make a Difference?

Walking in each other's shoes

• Disposition feedback
• Case studies
• Open communication
• Identified point of contact
• Lower readmission rates

2013 COPD 30-Day Readmission Rate

Next Steps

• Monthly meetings with coders
• Antibiotic selection for COPD order sets
• INTERACT Capability Tools