Care Redesign

TOPS: Telephonic Outreach in the Pulmonary Service at VA Boston Healthcare System

Case Study · September 26, 2018

Key Takeaways

  1. Nurse-directed telephonic outreach to COPD patients is a high-impact intervention that is not especially labor intensive.

  2. Telephonic engagement with recently hospitalized patients may effectively triage ambulatory patients. In other words, by reducing routine face-to-face follow-up of stable discharged patients, clinics can expedite visits for patients who need to see a specialist sooner.

  3. Even the best hospital discharge practices have their limits: most patients need to be encouraged to complete their medication regimens.

  4. Telephonic engagement combined with a patient-centered approach has the potential to decrease the rate of COPD readmissions.

The Challenge

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death in the United States and the fifth-leading cause of death among veterans. The rate of smoking among veterans is higher than that in the general population, and veteran status may confer an elevated risk of COPD.

All hospitals, but especially Veterans Association (VA) medical centers, must develop creative approaches to serve these patients as COPD carries large personal, medical, and economic burdens.

Nurse-driven programs involving the use of telemedicine represent one promising approach that has positively impacted patient care and reduced readmissions among the elderly and other populations with comorbid diseases. We were curious to see whether such a program could be effective for patients with COPD at VA Boston’s pulmonary clinic.

The Goal

Our goal was to create a simple yet effective intervention that would improve recovery, increase access to care, and reduce readmissions for patients with COPD. To that end, we implemented the Telephonic Outreach in the Pulmonary Service (TOPS) program for recently hospitalized COPD patients. We hypothesized that veterans who received telephonic outreach would be less likely to experience a COPD-related readmission compared with those who did not receive the intervention. We performed an 8-month pilot study on a small sample of patients in our clinic.

The Execution

The pulmonary clinic at VA Boston is a facility that includes three main campuses and five geographically dispersed community-based outpatient clinics within 40 miles of Boston. The pulmonary clinic is located at VA Boston’s principal tertiary inpatient medical center campus in West Roxbury, Massachusetts.

From April through December 2016, the hospital’s Quality Improvement Department provided the pulmonary nurse with a list of patients with COPD who had been discharged from VA Boston’s inpatient services. A readmission was defined as a COPD-related admission within 30 days after the index admission for COPD. We considered patients as having a comorbidity if a chart review revealed any of several selected conditions — specifically, congestive heart failure, diabetes, pulmonary fibrosis / other interstitial lung disease, asbestosis, lung cancer, kyphoscoliosis, or anxiety. Using telephonic outreach, the pulmonary nurse evaluated the risk of readmission and addressed the pulmonary needs of each high-risk patient.

The nurse used a standardized approach of contacting patients and made a maximum of four attempts before discontinuing further outreach. A consistent dialogue was used during all telephonic outreach. First, the nurse assessed symptom severity by conducting the validated COPD Assessment Test, a simple and reliable measure of health status that is useful for predicting COPD exacerbations in high-risk patients. Next, she reviewed the patient’s understanding of his or her medication regimen and adherence to the discharge plan. Finally, she determined the smoking status and the level of physical activity.

If the nurse felt that the veteran was at risk for potential COPD exacerbation based on the content of the call, she scheduled immediate evaluation through either the emergency department or a face-to-face appointment in the pulmonary clinic. At all times, the nurse provided targeted patient education, discussed lifestyle considerations, and addressed additional concerns based on the responses received.

A research associate performed regular chart audits for each patient who was discharged after a COPD admission. We compared (1) the rate of COPD-related readmissions and (2) the rate of follow-up visits within 2 weeks after the initial COPD admission between patients who had received the telephonic intervention and those who had not.

The Team

The team consisted of a pulmonary nurse, who was responsible for conducting weekly telephonic evaluation and management; a pulmonologist, who was responsible for championing the program, providing guidance, and expediting clinic evaluations when needed; and a clinic administrator, who was responsible for patient scheduling.

Metrics

During the course of this 8-month pilot program, 48 patients were admitted because of COPD, 96% of whom were male. As our program was launched in the spring, we suspect that the overall number of hospital COPD admissions was limited during the warmer months; thus, our overall sample size is small. In addition, we were unable to contact nearly half of the patients, further limiting the impact of our intervention. Key findings from our pilot program are listed below:

  • Nursing time required: Case identification and chart review prior to the initial telephone call required 20 to 30 minutes. Each telephone conversation lasted approximately 20 to 25 minutes. The ideal time of day to reach veterans was between 9:00 and 11:30 a.m. A total of 10 to 20 hours per week was required for this structured intervention.
  • Percentage of patients contacted: The pulmonary nurse successfully contacted 25 (52%) of the 48 patients on the COPD discharge list. The remaining 23 patients had been transferred to another facility (n = 3), had already been readmitted (n = 4), or could not be contacted within the threshold of 4 attempts (n = 16).
  • Comorbidities: One or more comorbidity was documented for 48% of the patients who received the TOPS intervention, compared with 57% of those who did not.
  • Medication reconciliation: The nurse found that 17 (68%) of the 25 patients who received TOPS did not adhere to the prescribed inhaler regimen. In addition, coaching and reinforcement was required for 67% (10) of 15 patients who were discharged with a steroid taper and 64% (9) of 14 patients who were discharged with antibiotics.
  • Readmission and follow-up: The readmission rate was 4% (1 of 25) for the patients who had received the TOPs intervention, compared with 17% (4 of 23) for those who had not. The rates of follow-up (i.e., a face-to-face evaluation within 2 weeks after discharge) were 32% (8 of 25) and 43% (10 of 23), respectively.

Where to Start

  1. Create a team that includes a minimum of one nurse and one clinician to focus on patients with COPD. The team could be expanded to include a respiratory therapist, physical therapist, dietician, mental health provider, or smoking cessation counselor.
  2. Define your high-risk COPD population and identify their needs. High-risk patients could be identified on the basis of their hospitalization history, smoking status, disease severity, specialty follow-up status, or a combination of these and other factors.
  3. Develop a strategy for the long haul that includes close follow-up after discharge from the hospital, increased patient and provider engagement, and the use of telephonic and in-clinic visits.

Funding

This quality improvement study was supported by an unrestricted educational grant from AstraZeneca to the Boston University School of Medicine’s Barry M. Manuel Continuing Medical Education Office. An IRB exemption for this initiative was provided by VA Boston Healthcare. The contents of this article do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Hurdles

The main limitations of this pilot study were that (1) we were unable to reach nearly half of the eligible patients, and (2) the rate of documented comorbidities was higher in the group of unreachable patients than in the group who were successfully contacted. It is possible that the unreachable patients were sicker or more vulnerable.

We suspect that veterans with severe illness or multiple comorbidities (including frailty, psychiatric disease, substance abuse, or cognitive/auditory dysfunction) are more challenging to contact. Furthermore, those who live alone without an advocate (spouse, family member, or caregiver) are harder to engage through clinic-based interventions only.

Unfortunately, these granular details are not systematically recorded in patient charts and may not factor into the initial risk assessments by clinicians or hospital administrators. We suspect that these barriers definitely impacted our outreach efforts and are insurmountable by telephonic outreach alone. In such cases, video visits and/or home visits may be more effective methods of outreach.

Lessons Learned

We were astonished to learn that more than two-thirds of the patients who were contacted in this pilot study did not adhere to discharge instructions and required additional coaching to complete steroid and antibiotic regimens. This finding reminded us that even the best discharge practices in the hospital have their limits once patients resume life outside the hospital. During follow-up, it is always appropriate to start with medication reconciliation.

Next Steps

Future directions include (1) continuing this program for a longer period to capture COPD admissions during the winter months, when exacerbations due to pneumonia, influenza, and other causes are prevalent; (2) incorporating video visits to increase patient engagement; and (3) expanding the program to primary care clinics in our system.

 

The authors thank Catherine Lafferty, MPH; Emily Jansen, MPH; Claire Murphy, NP; and Ronald Goldstein, MD.

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