Motivate patients to become independent

Klingensmith Healthcare kicked off a disease state management pilot program in December to help reduce hospital readmissions for COPD patients, but before doing so, company officials pored over clinical literature. Their goal: Make sure every facet of the program has a clinical basis, said Kim Wiles, the company's vice president of respiratory services.

"One of the biggest problems for COPD patients in the home is the inaccuracy of oxygen titration, which a lot of times takes them back into the hospital," she said. "So the key is to get them saturated."

Another key: a ton of personal attention, roughly 20 patient contacts in the first 30 days. These contacts include calls from clinical care coordinators and visits from respiratory therapists. In addition to educating the patient on how to manage his disease, the program requires him to set goals.

"We want to know what he wants to do after 30 days, and we won't take the answer, 'I want to be off my oxygen,'" Wiles said. "We want them to think about what they would like to do once they get their independence back, and we want to be there to help them. Goals are a great motivational tool."

Finally, at day 30, a respiratory therapist visits the patient and retitrates him. This is important because if the patient is no longer in an acute phase, the oxygen level can sometimes be reduced, allowing him to stay out longer and be more independent, Wiles said.

"We are trying to push independence," she said. "It is more than just understanding the disease. It's how to become independent with it."