Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE)
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Chronic Obstructive Pulmonary Disease Coordinated Access To Reduce Exacerbations (COPD CARE) evaluates patients who are recently discharged from the hospital or emergency department with a COPD exacerbation.
COPD CARE empowers interprofessional Patient Aligned Care Team (PACT) Clinical Pharmacist Practitioners and Nurse Care Managers (among other disciplines) to deliver high-quality COPD disease state management to our nation’s Veterans.
Origin:
October 2015, William S. Middleton Memorial Veterans' Hospital (Madison)
Adoptions:
47 successful, 3 in-progress
Awards and Recognition:
Diffusion of Excellence Promising Practice, VHA Shark Tank Winner, American Society of Health-System Pharmacists Best Practice Award
Partners:
Clinical Pharmacy Practice Office, Diffusion of Excellence, Office of Primary Care, Office of Rural Health, Quality Enhancement Research Initiative, VHA Innovators Network
Recent Updates
Overview
The problem
Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory illness characterized by airflow limitation and inflammation. COPD is a cause of significant morbidity, mortality and healthcare costs. Worldwide, COPD is the third leading cause of death, claiming 3 million lives in 2016. In the United States, COPD is the fourth leading cause of death
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Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory illness characterized by airflow limitation and inflammation. COPD is a cause of significant morbidity, mortality and healthcare costs. Worldwide, COPD is the third leading cause of death, claiming 3 million lives in 2016. In the United States, COPD is the fourth leading cause of death and was the primary reason for more than 923,000 emergency department visits in 2017 alone. COPD presents a substantial burden to our Veteran population, as there is a 3-fold greater prevalence of COPD among the US Veteran population. About 15% of U.S Department of Veterans Affairs (VA) healthcare users are affected by COPD; moreover, COPD is the fifth most prevalent disease in the Veteran population presenting a substantial patient burden. Additionally, patients diagnosed with COPD are disproportionally impacted by the current global COVID-19 pandemic, as COPD is the strongest predictive comorbidity for both severe disease and ICU admissions among those infected with COVID-19. COPD also has significant associated healthcare costs, with estimated costs of hospitalizations for acute COPD exacerbations totaling more than $11.9 billion in the United States according to a 2012 publication. Additionally, the national treatment cost for COPD management is expected to reach $49.0 billion by the end of 2020, a 53% increase from 2010. These significant healthcare costs in combination with the morbidity and mortality associated with COPD pose a significant problem for our Veterans and justify the need to improve management of this chronic disease state.
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The solution
While COPD is a progressive disease with a strong association with morbidity and mortality, it is also treatable, and opportunities exist to improve the management of COPD.
Chronic Obstructive Pulmonary Disease Coordinate Access to Reduce Exacerbations (COPD CARE) is a comprehensive, interprofessional, transitions-of-care service that incorporates best pr ... While COPD is a progressive disease with a strong association with morbidity and mortality, it is also treatable, and opportunities exist to improve the management of COPD.
Chronic Obstructive Pulmonary Disease Coordinate Access to Reduce Exacerbations (COPD CARE) is a comprehensive, interprofessional, transitions-of-care service that incorporates best practices to optimize delivery of COPD management to Veterans. COPD CARE was established in 2015 at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin (Madison VA) and has since been expanded to several VA Medical Centers across the country. The service was developed with the goal of improving post-discharge management of COPD for our Veterans following a COPD exacerbation. COPD CARE utilizes a team-based approach to foster collaboration across disciplines by involving Clinical Pharmacy Practitioners (CPP), Registered Nurse Care Managers and Primary Care Providers to deliver optimal care to Veterans to enhance COPD disease state management. In 2018, COPD CARE was selected as one of 11 national VA Promising Practices and was nationally recognized by the Diffusion of Excellence as a Gold Standard Practice. In 2021, COPD CARE as selected as a Best Practice by the American Society of Health-System Pharmacists. In 2022, COPD CARE awarded joint Office of Rural Health and Pharmacy Benefits Management funding. In 2023, COPD CARE was highlighted at the VA Senior Leaders Summit as a Promising Practice.
The COPD CARE service enhances the transition of care services provided to Veterans by individualizing care and promoting collaboration among providers. Services provided include hospital-based education, focused assessments over-the-phone, nurse and pharmacist wellness visits, annual provider visits, individualized referrals (i.e. tobacco cessation, pulmonary rehabilitation, spirometry testing) and inhaler technique assessment. COPD action plans are also created and provided to patients in combination with disease-state education. COPD CARE provides a platform for clinicians to provide evidence-based care to Veterans in alignment with the recommendations of the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. The 2020 GOLD guidelines emphasize that optimal management of COPD includes an interprofessional approach that incorporates assessment of inhaler technique, disease state education, management of comorbidities and a written COPD action plan, among other best practices.
By implementing the COPD CARE service, your VA site will have the opportunity to be involved in a nationally-recognized, interprofessional service that uses a collaborative approach to improve COPD management. See more
Chronic Obstructive Pulmonary Disease Coordinate Access to Reduce Exacerbations (COPD CARE) is a comprehensive, interprofessional, transitions-of-care service that incorporates best pr ... While COPD is a progressive disease with a strong association with morbidity and mortality, it is also treatable, and opportunities exist to improve the management of COPD.
Chronic Obstructive Pulmonary Disease Coordinate Access to Reduce Exacerbations (COPD CARE) is a comprehensive, interprofessional, transitions-of-care service that incorporates best practices to optimize delivery of COPD management to Veterans. COPD CARE was established in 2015 at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin (Madison VA) and has since been expanded to several VA Medical Centers across the country. The service was developed with the goal of improving post-discharge management of COPD for our Veterans following a COPD exacerbation. COPD CARE utilizes a team-based approach to foster collaboration across disciplines by involving Clinical Pharmacy Practitioners (CPP), Registered Nurse Care Managers and Primary Care Providers to deliver optimal care to Veterans to enhance COPD disease state management. In 2018, COPD CARE was selected as one of 11 national VA Promising Practices and was nationally recognized by the Diffusion of Excellence as a Gold Standard Practice. In 2021, COPD CARE as selected as a Best Practice by the American Society of Health-System Pharmacists. In 2022, COPD CARE awarded joint Office of Rural Health and Pharmacy Benefits Management funding. In 2023, COPD CARE was highlighted at the VA Senior Leaders Summit as a Promising Practice.
The COPD CARE service enhances the transition of care services provided to Veterans by individualizing care and promoting collaboration among providers. Services provided include hospital-based education, focused assessments over-the-phone, nurse and pharmacist wellness visits, annual provider visits, individualized referrals (i.e. tobacco cessation, pulmonary rehabilitation, spirometry testing) and inhaler technique assessment. COPD action plans are also created and provided to patients in combination with disease-state education. COPD CARE provides a platform for clinicians to provide evidence-based care to Veterans in alignment with the recommendations of the 2020 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. The 2020 GOLD guidelines emphasize that optimal management of COPD includes an interprofessional approach that incorporates assessment of inhaler technique, disease state education, management of comorbidities and a written COPD action plan, among other best practices.
By implementing the COPD CARE service, your VA site will have the opportunity to be involved in a nationally-recognized, interprofessional service that uses a collaborative approach to improve COPD management. See more
The results
Through coordination of existing care structures, including the Patient Aligned Care Team (PACT), COPD CARE has been shown to increase patient access to timely care post- discharge and reduce COPD 30-day readmission rates. Initial implementation of the service at the Madison VA in 2015 showed a 100% increase in access to timely care post-discharge and a redu
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Through coordination of existing care structures, including the Patient Aligned Care Team (PACT), COPD CARE has been shown to increase patient access to timely care post- discharge and reduce COPD 30-day readmission rates. Initial implementation of the service at the Madison VA in 2015 showed a 100% increase in access to timely care post-discharge and a reduction of COPD-related 30-day hospital readmission rates to 0%.8 More recently, COPD CARE is associated with a 6% readmission rate, significantly below the 20% national average. COPD CARE has shown that a significantly greater portion of Veterans (87%) complete follow-up with a PACT clinician within 30 days of hospital or ED discharge compared to the standard of care (7%) (p < 0.05). In addition to improved access to care and reduced readmission rates, the COPD CARE service also improves COPD management for Veterans through the interventions made by CPS providers. The COPD CARE service increased CPS encounters for COPD management by 890%. A significantly greater percentage of patients receiving COPD CARE were placed for tobacco treatment (8%, p < 0.05), pulmonary function testing (18%, p < 0.05) and telehealth services (7%, p < 0.05) compared to those receiving standard of care. Additionally, 75% of patients managed through the COPD CARE service received follow-up care within one month or less compared to 20% in the standard care group (p < 0.05). Finally, corrections or changes to inhaler technique or inhaler dosing frequency were made for a 49.6% of patients, and 50.4% of patients required medication optimization. The COPD CARE service also enhances engagement in comprehensive medication reviews (CMR), as 85% of patients managed through the service participated in a CMR during their COPD Wellness Visit. In summary, the COPD CARE service improves access to care, reduces readmission rates, and identifies more patients for referral services compared to the current standard of care, which can significantly improve patient care outcomes.
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Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Videos
Above:
Sample COPD CARE Academy Training Tutorial: Discover how COPD CARE empowers your team to deliver high quality COPD transitions of care management to Veterans
Implementation
Departments
- Pharmacy
- Administration
- Nursing services
- Telehealth
- Primary care
Core Resources
| Resource type | Resource description |
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PEOPLE |
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PROCESSES |
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TOOLS |
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Files
- Pre-Implementation Workbook for the COPD CARE Academy COPD CARE Pre-Implementation Workbook
- Overview of the COPD CARE Service COPD CARE Service Overview
Contact
Comment
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Email COPDCARE@va.gov with questions about this innovation.
About
Origin story
With COPD as a frequent cause of 30-day hospital readmission, the COPD CARE team sought an opportunity to improve post-discharge COPD management.
COPD CARE offers a means of interprofessional coordination for enhanced COPD management, resulting in a statistically significant reduction in a 30-day readmission rate reduction and almost doubling access to ca
...
With COPD as a frequent cause of 30-day hospital readmission, the COPD CARE team sought an opportunity to improve post-discharge COPD management.
COPD CARE offers a means of interprofessional coordination for enhanced COPD management, resulting in a statistically significant reduction in a 30-day readmission rate reduction and almost doubling access to care within 30 days of discharge.
Original team
Edward Portillo, PharmD
Diffusion of Excellence Gold Status Fellow, Madison VA
M. Shawn McFarland, PharmD, FCCP, BCACP
National Clinical Pharmacy Practice Program Manager, Clinical Pharmacy Practice Office, VA Pharmacy Benefits Management Services
Sarah Will, PharmD, BCPS
National Clinical Pharmacy Practice Program Manager, Clinical Pharmacy Practice Office, VA Pharmacy Benefits Management Services
Molly Lehmann, PharmD
Clinical Pharmacist Practitioner, Madison VA
Timothy Hagen, MBA, LSSBB
VHSO Systems Redesign and Improvement Coordinator, Veterans Health Care System of the Ozarks
Awesome concept- however, would be better if included Home O2 use, why O2 does not improve symptoms, and importance of PAP use, sleep and niutrition.
Looking to get started? Complete the "COPD CARE Pre-Implementation Checklist"!
Our COPD CARE workgroup is excited to join the Diffusion Marketplace space!
Please do not hesitate to contact our workgroup with any questions or interest in implementing our practice. Email: COPDCARE@va.gov
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