The PRAXIS Nexus The PRAXIS Nexus

Promising Practices in COPD Care: Rutland Regional Medical Center

Posted on December 11, 2015   |   

This interview was compiled by Kristen Willard, M.S.

Let’s start by talking a bit about your organization.

The biggest community hospital in Vermont and the second largest hospital in the state, Rutland Regional Medical Center has been providing high quality healthcare to the Rutland Region for more than 100 years.

As the needs of our community have grown and changed, so has Rutland Regional, adding services, staff and facilities. As of this post, Rutland Regional Medical Center is a 123-bed hospital, employing over 1,600 professional and support staff including 227 providers trained in 36 specialty areas.

Rutland Regional Medical Center's COPD Care Team

At Rutland Regional we manage and adapt to change and growth while continuing our focus on a high standard of personalized, quality medical care, adding key specialties to serve community needs, and focusing on attracting and recruiting highly trained doctors, nurses and staff. We are committed to providing the services, both in and out of the hospital, required to maintain the health of not just our patients, but the entire community.

Can you please describe your COPD care and readmissions reduction approach?

Building on a recently completed successful effort to reduce readmission rates in patients with congestive heart failure (CHF) in 2013, Rutland Regional Medical Center shifted our focus and efforts to COPD. The primary structure used to do our work is a community-wide collaborative: A large group of providers and organizations that make up most of the healthcare in Rutland County for these patients. This collaborative, of which there are approximately 30 members including:

  • Hospital-based functions such as nursing, emergency services, hospitalists, case management, performance improvement, respiratory therapy, education and palliative care.
  • The three local skilled nursing facilities.
  • The two home health agencies.
  • Pulmonology.
  • Primary care physicians.
  • Community health team.

These groups, and other organizations from the community, come together and work on this common goal of reducing 30-day hospital readmissions for COPD patients each month. When the collaborative meets, the group shares ideas, information, best practices and identifies the care redesign changes necessary to make improvements for COPD patients.


  1. Jointly developed standardized clinical protocols for managing COPD patients in the community setting and determining the clinical criteria to be used for sending a patient to the hospital.
  2. Utilization of a COPD Transition Protocol at hospital admission to provide patient education, medication instruction, tobacco cessation and assist with arranging PFTs, inpatient and outpatient pulmonary follow-up.
  3. Improved the coordination and communication between the hospital, skilled nursing facilities, home health agencies and physician practices so that when patients are admitted and then discharged from the hospital to another organization we improve the “transitions of care.”
  4. Evaluate the potential for more patients to receive home health interventions if they are eligible and would benefit from those services.
  5. The development of a standard of patient-appropriate clinical language and advice for patients as they are treated throughout the healthcare continuum in the Rutland community. We also developed a standard, effective patient COPD journal to empower and encourage the patients to better self-manage.
  6. Provide a follow-up telephone call to each COPD patient within 1-3 days of hospital discharge. This is done so we can answer any questions the patient may have. This also helps to ensure that the patient understands and follows their discharge plans. This includes getting prescriptions filled, dietary and other behavioral modifications (such as tobacco cessation), follow-up appointments with their physician and similar activities.
  7. Ensure the patient has a good understanding and an accurate list of the medications that he or she she is taking. This list is also shared with others caring for the patients to ensure medication safety.
  8. Utilization of monthly clinical case review to determine areas of success and areas of improvement, if applicable.
  9. For those patients with advanced stages of COPD, we found it may be beneficial to have palliative care discussion and guidance with a nurse or patient’s doctor. This will help ensure the patient’s wishes and best interests are known and factored into care making decisions.
  10. We have added an additional pulmonary provider to our organization, which allowed for better access to a pulmonary specialist for this patient population.

What elements of this approach do you think make you most successful?

Alignment of our community partners and the willingness to make this work a priority makes this collaborative successful. The participation and engagement of all the persons at the table have improved coordination and collaboration between all of our stakeholders. This has resulted in an improvement of the quality of our care for our patients with this disease. Our work with the CHF collaborative has set the foundation and paved the way for COPD and other disease management for the future.

What do you find about working in COPD care most challenging?

Competing priorities and scarcity of resources among collaborative members. In addition, we found patient adherence to their prescribed plans of treatment a challenge at times, as well as patients’ understanding of the disease, consequences and treatment options.

What do you find most rewarding about this work?

Having our healthcare community come together to work on this common goal to provide the best care for our patients, and the community, has been very rewarding. The improved quality of our care for our community has been the most important and rewarding benefit.

What other things would you like to tell PRAXIS NEXUS readers about your experiences?

Although it may seem daunting to begin a project like this, we can assure you from experience that it is doable and well worth all of the effort that goes into getting it up and running. Now, having established a foundation of trust, teamwork and cooperation, we are able to build on that foundation for future work. As the work of the collaborative changes, ongoing management and support is necessary to ensure that the improvements put into place from our project stay anchored.

This page was reviewed on March 5, 2020 by the COPD Foundation Content Review and Evaluation Committee


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  • I noticed that there's no discussion of how you connect or improve care for those individuals who are lucky enough to have stayed out of the hospital. Some of them undoubtedly are not hospitalized because they're doing all the right things, but some are just there, waiting for the other shoe to drop.

    I'd suggest some additional things from the point of view of the patient:

    Educate docs (especially primary care) on the importance of developing an action plan with the patient that both understand and can implement easily. Going to the ER should NOT be first on the list! In fact, I'd feel better if it weren't on the list as all, but.......the point is to get the patient to be proactive very early to avoid hospitalizations in the first place.

    Educate docs on the importance of exercise or pulmonary rehab. You don't have to have a PR program to learn how to help yourself. I've never done PR, but I work out every day, even when I'm on the road (I travel a lot!), and so can every other patient. You don't need a gym and you don't need supervision most of the time; you need common sense and your doc to tell you clearly what your limitations should be.

    Educate docs on the importance of support groups, either in-person or on-line. There's lots of the,