The PRAXIS Nexus The PRAXIS Nexus

Unique Team Helps this COPD Readmissions Reduction Program Get Positive Outcomes

Posted on July 02, 2018   |   

By Danny Pham, PharmD, BCPS, BCACP, BCGP

Inpatient Care Transitions Pharmacist

Baylor Scott & White Medical Center – Plano

Before we started our COPD program at Baylor Scott & White Medical Center – Plano, our readmission rate was similar to other institutions across the country. We knew there was more we could do to help our patients better understand their condition, be more engaged with controlling their respiratory symptoms, and take a proactive role in slowing the progression of their disease. We also knew that in order for the program to be successful, we had to make sure all members of the team had a good understanding of each other’s roles. Another challenge was how to best incorporate varying levels of expertise to work within an integrated COPD care model.

How does the program work?

In our program, preventing COPD readmissions starts the moment the patient steps into the hospital. After a patient is identified, respiratory therapists reconcile which bronchodilators the patient was on prior to their admission. They also discover any inappropriate use of inhalers and/or poor adherence, provide education using a COPD action plan, and work with the pharmacy team to optimize COPD treatment once patients are stable before their discharge home.

Plano COPD results


As a pharmacist, my role is first, to determine if patients were on optimal therapy prior to their hospitalization based on the GOLD 2017 updates. I then work closely with our hospitalists to tailor COPD treatment for home, based on the specific needs of the patient, side effects, their preference of inhaler device, and of course, cost considerations. Our team provides education on proper inhaler techniques and teach-back at discharge for inhalers patients were on before they were hospitalized as well as for new ones recently changed or added.

Identifying barriers before discharge

Prescriptions can be sent to our Baylor Scott & White – Plano outpatient pharmacy, where the medication concierge program delivers newly prescribed medications to the patient at bedside before they even leave the hospital. Not only does this serve as a convenience to our patients, it helps us identify issues with cost early on and allows our team to troubleshoot financial barriers which may lead to poor inhaler adherence. Our care management team offers information on resources for financial assistance to help with the affordability of breathing treatments.

The care management team and Jennifer Kyser, BSN, RN-BC, our readmission outcomes manager, work closely to schedule follow-up appointments and pulmonary rehab, set up home O2 for those who qualify, and schedule patients with a new provider if they do not currently have an outpatient pulmonologist or PCP to manage their COPD.

Transitional care services involve a paramedicine team and many others

Jennifer also enrolls eligible patients who decide to opt in for our outpatient transitional care services. The community transitional care team includes Plano Paramedicine and Baylor Scott & White advanced practice practitioners. Josh Clouse, Plano Community Paramedicine Coordinator, and his team worked with us to help develop this Paramedicine COPD program. The program is an extension of our COPD efforts in the hospital with a few important additions. They make house visits to conduct wellness checks, draw labs, collect medication reconciliation, and help identify risk factors for readmissions. The paramedicine team reinforces the patient’s understanding of their condition, promotes self-care to better manage their COPD, assesses proper inhaler techniques, and helps patients avoid environmental triggers that may exacerbate their condition (e.g., checking air filters and reducing dust around the home).

Training for the paramedicine team consisted of time spent shadowing Dr. Omar Awad, one of our Health Texas Provider Network pulmonologists, in his outpatient clinic, learning from respiratory therapists in the pulmonary rehab clinic, and observing our hospitalists provide bedside care for patients with acute exacerbation of COPD (AECOPD). Dr. Mark Millard, medical director at the Baylor Martha Foster Lung Center was also gracious enough to have us shadow his team of highly skilled respiratory therapists for our program. Dr. Millard has been instrumental in mentoring and educating many clinicians to better serve our community for patients with COPD. This partnership between the paramedicine team and our outpatient pulmonary services was pivotal in creating the Paramedicine COPD program. Our emergency department team also provided valuable input regarding treatment and monitoring parameters for patients with acute symptoms who may fall in between the Yellow/Red Zone of our COPD action plan.

A successful readmissions reduction program requires the coordinated efforts of individuals from various disciplines who are passionate and knowledgeable about respiratory care

Addressing pertinent co-morbidities and psychosocial factors in the outpatient setting is crucial to the success of any COPD program. Josh and his team use the PHQ-9 questionnaire to assess if the patient is depressed. If the patient scores high on the survey and has not been treated for depression, the paramedicine team will notify the PCP’s office to determine if treatment is needed. Paramedicine also assesses the volume status of COPD patients with co-morbid congestive heart failure, and have the option of providing intravenous furosemide in the field based on a physician protocol in use with telemedicine.

The Paramedicine COPD program is still evolving. In the future, our hope is to have firefighters and pharmacy students provide smoking cessation education and follow-up in the homes for those who are ready to quit. The team is also exploring the possibility of administering influenza and pneumonia vaccines in the home with help from a local school of pharmacy.

The role of pharmacy students

Pharmacy students play a significant role in our program. They go on ride alongs with the paramedics to see patients in their homes so they can assist with questions about medications. They also reconcile patients’ medications by comparing their discharge medication list to the medications they have recently filled or actually have in their home. With my direct supervision, the pharmacy students also provide basic pharmacologic recommendations. As you can see, there is a lot of overlap with many of the interventions we provide in the hospital. We’ve learned that patients often require additional reinforcement after discharge, due to limited comprehension, low health literacy, or the often overwhelming nature of their hospitalization.

Plano COPD Team

A unique team

Our interdisciplinary team includes pulmonologists, respiratory therapists, cardiopulmonary trained RNs, readmissions program outcomes manager, LMSW (licensed master social worker) or RN care manager, director of healthcare improvement, CP-C (community paramedicine coordinator), hospitalists, ED physicians, advanced practice providers, physical/occupational therapists and a clinical pharmacist. The team works closely with hospitalists to optimize COPD care for patients in addition to other penalty diagnoses identified by CMS.

The importance of proper inhaler use – a big issue - reinforced by the entire team

In working with this program, the thing that surprised me most is how important it is to reinforce proper inhaler technique prior to a patient being discharged. Some patients we see at discharge have not been properly trained or asked to provide teach-back to demonstrate a thorough understanding of the appropriate use of their inhalers.

It should be the responsibility of prescribers, respiratory therapists, pharmacists, and/or community care team members to assess the patient’s understanding of their condition and ensure they are comfortable with properly using their inhalers. “

"This education was much needed. My inhalers were going to make me bankrupt. Switching me over to a 3-in-1 inhaler was a God send! I’m breathing better now. Thank you very much!”

One patient was using her LABA/ICS as directed, but she thought her LAMA was to be used as needed for shortness of breath. We’ve also had patients who are adamant that their maintenance inhalers do not work. Often this is because they are either rationing them due to cost, or have not been educated on how their long-acting inhalers are meant to be used daily to prevent flare-ups and slow disease progression. They don’t always understand that their rescue inhalers are to be used as needed to treat acute respiratory symptoms, but they also have to know that overuse or exclusively relying on their rescue inhalers to treat their COPD may increase their risk of side effects such as increased heart rate, nervousness, or in some cases trigger irregular heart rhythms. These major knowledge gaps can be prevented at many different levels of their COPD care.

Delivering a consistent message throughout the process

It’s essential to thoroughly train key members of the team to ensure consistency in the COPD education and message being delivered to the patient. For example, it’s unreasonable to expect every pharmacist to know which inhalers contain a LABA/LAMA vs. LABA/ICS or to expect a respiratory therapist to properly educate on every DPI or MDI device available without the appropriate training. The ED staff can be trained to inform patients being admitted for an acute COPD exacerbation that they’ll be started on nebulizer treatments, steroids, and possibly an antibiotic to help reduce their respiratory symptoms. They can also tell them that once they are stable they will likely be transitioned to a maintenance inhaler to prevent further flare-ups and hospitalizations. This will make our jobs easier on the back end when, prior to discharge, we’re trying to optimize our patients’ breathing treatments and educate them on the importance of the daily use of their long-acting maintenance inhalers. Delivering the same message throughout their stay will promote improved COPD self-care and better control of their breathing.

It truly takes a village to implement this program. Our innovative readmissions team focuses on making a difference in the lives of those we care for and we are fortunate to have overwhelming support from our executive leadership team who believe in creating a unique patient experience here at Baylor Scott & White – Plano. We’ve learned a lot and established a great program but we’ll always have more work to do. The program is evolving every day.

This page was reviewed on February 13, 2020 by the COPD Foundation Content Review and Evaluation Committee


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  • This is wonderful. Excellent job!
    We operate very similar in our System. It is unbelievable how much some are paying for inhalers, and with a little effort, the price gets dramatically reduced.
    This is definitely the future model of care. Have you considered home follow up visits?

    • Thank you for the kind comments. We always love hearing what other health-systems are doing successfully as well as share ideas with one another to help our COPD patients be better informed about their respiratory condition and learn to breathe better.

      I agree that a little effort goes a long way. Cost is a big factor driving adherence to maintenance inhalers. I always get asked which inhalers work the best. The simple answer is, "It's the one you can use and the one you can afford".

      Switching patients to a once a day DPI is great at promoting daily adherence, but not all patients with reduced inspiratory flow can forcefully breathe in a dry powdered formulation. Some patients with poor coordination may benefit from the use of a spacer, which we typically provide if they are on a pMDI. However, the number of actuations may be cumbersome for a few patients. Soft-mist inhalers have higher lung deposition, but may not be the most suitable option for patients with severe RA or dementia based off of my experience.

      We look at all of these factors when making a recommendation for our patients. Once the discharge prescriptions have been written or sent in to the patient's preferred pharmacy, we work with our awesome team of RN care managers and social workers to ensure we send our patients home on inhalers they can afford. Many also qualify for patient assistance programs from the manufacturer based off of their household income.

      Our Plano Paramedics conduct post-discharge follow-up visits to see our COPD patients in their homes. My pharmacy interns often participate in ride alongs with these highly trained paramedics to assist with med reconciliation and to reinforce COPD education. We also have advanced practice RNs/NPs who perform home visits for patients eligible for Baylor Scott&White post-acute transitional care services. Hopefully we'll be able to have respiratory therapists participating in the homes visits as well. How cool would that be?
  • I thrive on reviewing different successful models of what we do! Congratulations on your success and thank you for sharing some great tools for successfully achieving better outcomes! You are correct, it takes a village, whose villagers have their eyes wide open and are willing to learn and teach something new continuously.
    • Thank you Daine! You're absolutely right. In order to have a successful program, it's important to have various disciplines willing to share their expertise with the team and open to learning from other care team members. I'm constantly learning something new everyday.

      For example, I was asked by a RT during the initial in-service for proper inhaler techniques that my pharmacy intern and I gave, if we had heard of tiotropium capsules for handihaler devices being recalled or not being filled with sufficient drug in the capsules. We had not. Apparently, the patient stopped taking his LAMA and had collected a bagful of the capsules to show our RT. We had an aha moment when my intern discovered that tiotropium capsules only contained a small amount of the powder (~one-tenth of the capsule filled). We now counsel patients on this very point if patients are newly started on a tiotropium handihaler device to assure them there is medicine in the capsules. It was the collaboration between pharmacy and our respiratory therapy team, which made it possible for us to improve our COPD education in the hospital.

      I'll share one more example of continued learning from others. I came across a colleague, who was trying to explain the difference between maintenance vs. rescue inhalers by comparing it to preventing fires vs. putting out fires (fires = being COPD flare-ups/exacerbations). I began using this in my discharge teachings and have found success with it by asking my patients, "What's more important, preventing fires or putting them out?". They would always answer both. I would then proceed by saying that although you may not notice the instant relief that you get with a rescue inhaler or nebulizer, it's equally important to use your maintenance inhalers to prevent frequent episodes of worsening shortness of breath. They tend to have a clearer picture when it's explained in this manner.
  • Hi Danny,
    Excellent work. May I contact you directly with questions?

    Kelly Giber

    • Thank you Kelly! I would love to chat with you. I'll be reaching out to you shortly.

      Best regards,
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