Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes airflow blockage and breathing-related problems. It is the third leading cause of death in the U.S., behind heart disease and cancer.
One of five patients admitted to the hospital with COPD is readmitted within 30 days, and up to half of these readmissions may be preventable. Drivers of readmission are complex and multifactorial. Approximately 80 percent of COPD patients have at least one comorbidity, and 50 percent have four or more. Additionally, many patients with COPD are frail, debilitated, and have high anxiety and depression levels that complicate management.
In 2017, more than 3,000 patients with COPD were admitted to downtown Penn Medicine hospitals over 5,000 times – 20% of whom were readmitted within 30 days.
BreatheBetterTogether (BBT) is a hospital to home transition program for patients with COPD that facilitates the development and implementation of personalized home-based interventions.
The program leverages a customized Agent dashboard to identify high-risk hospitalized patients with COPD. This technology enables respiratory therapists to engage with patients early in their hospitalization to establish a trusting relationship and conduct self-management training.
Before discharge, patients are enrolled in a remote-monitoring program powered by Way to Health to detect early symptoms of clinical decline in the outpatient setting. BBT patients receive a daily text message asking them if they feel better, worse, or the same. If a patient responds that they feel worse, the BBT team is immediately alerted. The inpatient respiratory therapist who cared for the patient during their hospitalization conducts an evaluation by phone, provides guidance and reassurance, and, if necessary, rapidly escalates unresolved issues to the on-call pulmonologist.
For patients whose needs cannot be met over the phone, a Penn Cavalry visit is triggered. Cavalry visits entail an experienced Penn Care at Home nurse making a timely acute care visit to the patient's home. After evaluating the patient, the nurse contacts the on-call pulmonologist to coordinate interventions to prevent rehospitalization, such as administering IV corticosteroids, antibiotics, and/or diuretics. If a patient is deemed too ill to treat at home, the nurse contacts emergency medical services and waits with the patient until they arrive for transport to the hospital.
BBT improves patient outcomes and reduces readmission rates by alerting care teams to patient issues early - when they can potentially be resolved with home-based interventions.
In the initial pilot phase with more than 150 high-risk COPD patients at the Hospital of the University of Pennsylvania (HUP), the introduction of BBT led to a 32 percent reduction in 30-day readmissions, and Penn Cavalry prevented 82 percent of readmissions. Together, these programs result in cost savings to the health system of approximately $10,000 per patient.
BBT is the standard of care at HUP, Pennsylvania Hospital, Penn Presbyterian Medical Center, and Lancaster General Health.
Patients with COPD are at increased risk of severe illness from COVID-19. The BBT program enables more COPD patients to be managed at home rather than in hospital settings, thereby decreasing the risk of exposure for this vulnerable population. Additionally, the BBT logic was used as a blueprint to create COVID Watch, a program launched at the start of the pandemic. COVID Watch enables patients who are confirmed or likely to have COVID-19 but not sick enough to need hospitalization to be monitored at home.