Opportunity 

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 United States, behind heart disease and cancer.  

One in 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 Penn Medicine's downtown hospitals, and 20 percent were then readmitted within 30 days after discharge. 

Intervention 

Breathe Better Together (BBT) is a hospital-to-home transition program for patients with COPD that enables personalized home-based intervention.  

The program leverages a customized 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 being discharged, 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. Then, 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 Cavalry visit is triggered. Cavalry visits entail an experienced Penn Care at Home nurse making a same-day 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. 

Impact 

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 Cavalry prevented 82 percent of readmissions.  

In 2022, we expanded BBT and Cavalry to serve patients at Penn Presbyterian Medical Center (PPMC) with the assistance of a one-year grant from Independence Blue Cross. Approximately 150 subjects participated in the second pilot. Unfortunately, we did not see a significant reduction in 30-day readmissions. However, several very important insights were uncovered. For example, we found that 45 percent of readmissions were primarily due to factors other than COPD. We also observed that engagement with the texting program was lower than expected, with only 42 percent of patients responding to at least 80 percent of daily texts and 28 percent of patients responding to less than 20 percent. For readmissions among relatively engaged participants (>70 percent response rate to daily texts), 77 percent responded on the day of their readmission, but only 8 percent replied that they were feeling worse and needed assistance on the days leading up to readmission, illuminating missed opportunities to intervene. Cavalry visits, however, did prove to have clinical utility. Among 20 patients receiving a Cavalry visit for a dyspnea crisis with concern for potential return to the emergency department, 17 were deemed safe for treatment at home. All 17 remained home for at least seven days following their Cavalry visit, and 15 stayed home for a full 30 days. EMS was contacted for the three patients deemed unsafe for treatment at home, and the visiting nurse remained with the patients until EMS arrived. Two of these patients were admitted to the medical intensive care unit upon arrival at the hospital, and the third was admitted for an inpatient lung transplantation workup. This pilot helped confirm that Cavalry visits are a powerful tool for discriminating between COPD patients who may be safely treated at home and those who will require hospital resources.

BBT is active at Lancaster General Health and Chester County Hospital (CCH). At CCH, the 30-day COPD-related readmission rate has dropped from 8.5 percent to 5.4 percent since the introduction of BBT and a COPD navigator in 2023.