Implementation of a Pulmonary Disease Navigator Program for 30-day Chronic Lung Disease Readmission Reduction

Event Time

Originally Aired - Thursday, March 14 1:00 PM - 2:00 PM Eastern Time (US & Canada)

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Event Location

Location: W308A

Event Information

Type: General Education

Session ID: 220

Title: Implementation of a Pulmonary Disease Navigator Program for 30-day Chronic Lung Disease Readmission Reduction

Description: This presentation explores the multidimensional approach undertaken to address Chronic Obstructive Pulmonary Disease (COPD) readmissions within the framework of the Hospital Readmission Reduction Programs (HRRP). Established in October 2012, HRRP aimed to reduce payments for excess readmissions, promoting a shift toward value-based care. COPD, a major contributor to healthcare costs, is estimated to incur $49.9 billion annually in the United States, with indirect costs constituting 41% of the total.

With COPD as a significant cause of disability and the third leading cause of death in the US, the imperative to mitigate its impact is evident. This presentation delves into a comprehensive COPD Playbook developed using the international survey, Global Initiative for Chronic Obstructive Lung Disease data and the organization's baseline COPD outcomes. This playbook guides a multidisciplinary care team utilizing integrated electronic medical record (EHR) solutions, including a COPD dashboard, predictive scoring, evidence-based protocols, and order sets. The approach centers around fostering communication, care coordination, and patient engagement to enhance transitional care.

Through an initial analysis within the Intermountain Healthcare System, a COPD 30-day readmission rate of 18.2% was identified. Implementation of the COPD Playbook, driven by the Pulmonary Disease Navigator (PDN) model, resulted in a significant 7% reduction in 30-day hospital readmissions for COPD patients. This success underscores the efficacy of leveraging EHR tools and a collaborative care approach in achieving positive outcomes, aligning with the broader goals of HRRP and contributing to improved patient care and healthcare cost management.

Level: Advanced

Format: 60-Minute Lecture

Learning Objective #1: Describe the alignment of care pathways with the primary objective of reducing readmission rates and discusse how a multidisciplinary care team can utilize electronic medical record tools, such as COPD dashboards and predictive scoring, to develop and implement a focused plan. The ultimate goal is to exhibit how these tools lead to substantial reductions in 30-day hospital readmissions, enhancing transitional care for COPD patients.

Attendees will gain a comprehensive understanding of the strategic planning required to adapt known care elements into a targeted playbook. This approach promises tangible improvements in COPD patient outcomes and aligns with broader healthcare quality improvement initiatives.

Learning Objective #2:  Discuss the recognition and seamless integration of respiratory care throughout the continuum of COPD patient management, spanning from inpatient to outpatient settings. Participants will acquire insights into optimizing care transitions, enhancing patient outcomes, and contributing to a comprehensive approach in COPD management.

Learning Objective #3: Describe designing and implementing a care plan/pathway for COPD patients, employing a care dashboard and the Pulmonary Disease Navigator model. The focus is on delivering high-touch, personalized care through effective utilization of these tools for improved patient outcomes and satisfaction.

Learning Objective #4: Detail patient and home caregiver awareness of COPD care plans, emphasizing COPD processes, referral resources, medication compliance via delivery devices, tobacco cessation, and recognizing early symptoms for timely intervention. Participants will gain insights into fostering patient empowerment, reducing exacerbations, and preventing hospital admissions.

Learning Objective #5: Discuss the necessity for advanced IT/EHR solutions, incorporating artificial intelligence, to effectively scale initiatives for enhanced population health management. Participants will recognize the urgency in adopting cutting-edge technology, with planned implementation in 2024-2025, for more robust and efficient healthcare solutions.


Continuing Education Credits

  • ACPE – 1 Credit(s)
  • CAHIMS – 1 Credit(s)
  • CME – 1 Credit(s)
  • CNE – 1 Credit(s)
  • CPD UK – 1 Credit(s)
  • CPHIMS – 1 Credit(s)

  • Tracks



    • Patient Experience


    • Chief Digital Officer/Chief Digital Health Officer
    • Chief Quality Officer and Chief Clinical Transformation Officer
    • Clinical Informaticist