Blogs

I think you are both on the right track. It appears that Becky started this some time ago. I'd be interested if Becky could share her outcomes and also how the COPD Specialists provide the post-hospitalization follow up if the pt is discharged to a SNF. Do you work with the SNF in the continued care requirements of the patient? I think it would be great to have a hospital COPD Specialist RT colleague for us to work with from the SNF (we work in SNF's) to assist in care coordination/transition of care needs for the patient.
Lisa

Hi Garry,
The organizational chart for our department includes the "Disease Management" section, under which Pulmonary Lab, Pulmonary Rehab, Asthma Education, COPD Education and Tobacco Education fall. Several years ago we undertook a systems change project to sandardize COPD care. At that time, a new Respiratory Therapy Clinical Specialist position was created.
The Specialist provides case managment for patients with chronic lung disease and communicates with our providers and associates to achieve desired patient outcomes. They are also responsible for fostering an interdisciplinary team that cooperatively improves overall performance outcomes, such as length of stay, cost of care, and reduced readmissions for specific diagnosis related groups (DRGs).
Early on, we identified the need to include patient education and transition planning to the role of the Specialist. Currently, the COPD Specialists work very closely with the patient, their family/support, and inpatient and ambulatory healthcare providers to identify barriers to discharge and problems that may lead to readmission. They then seek to address/resolve these issues before discharge. The Specialists also act as a contact person for the patient and other care providers for the continuation of the care plan. They provide post-hospitalization follow-up, which will soon include phone calls to the patient post-discharge and then every month for one year.
In addition, every patient admitted with COPD exacerbation is evaluated for appropriateness to attend Pulmonary Rehab; nearly every patient is discharged with an order for that service. Pulmonary Rehab provides excellent ambulatory "eyes" on the patient to help prevent ED visits and hospitalization by catching healthcare issues early.
Becky