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

The Hospital Readmission Reduction Program (HRRP) was established to reduce payments for hospitals with excessive readmissions. HRRP, a Medicare program, encourages hospitals to improve patient care coordination and engagement to reduce avoidable readmissions. Chronic Obstructive Pulmonary Disease (COPD) in the US incurs an estimated annual cost of $49.9 billion, with indirect costs comprising 41%. COPD is a significant cause of disability and the third leading cause of death in the US, affecting over twelve million diagnosed individuals, and potentially many more undiagnosed due to its slow development. A 2014 report indicated COPD's annual economic cost at over $289 billion. 

A study within Intermountain Healthcare System found an 18.2% 30-day COPD readmission rate. To tackle this, they developed a COPD Playbook driven by a multi-disciplinary team, integrating tools like a COPD dashboard and evidence-based protocols in the electronic medical record. The Pulmonary Disease Navigator (PDN) model further reduced 30-day readmissions by 7%. 

Key lessons from this initiative include emphasizing disease-specific care goals, integrating respiratory care across inpatient and outpatient settings, using care dashboards for personalized care plans, increasing patient and caregiver awareness about COPD management, and recognizing the need for advanced IT/EHR solutions, including artificial intelligence, for improved population health management by 2023.