In the U.S. state of Alabama, a hospital system collaborated on an initiative known as the Integrated COPD Care Initiative, to develop an end-to-end integrated COPD care program.
The objectives of the program aligned with value-based care: reduce avoidable readmissions and associated costs, improve health outcomes, and improve patient engagement in the post-acute setting.
The program included evidencebased strategies for care transition management, care coordination, and patient engagement. Focus areas included:
- Early detection of COPD within a patient’s hospital stay
- Ongoing home monitoring after hospital discharge, with HME respiratory therapists (RTs) transmitting data into the hospital electronic health record (EHR)
- Patient education
- Ongoing analysis of patient data
- Continuous assessment of the efficacy of clinical pathways
After thorough 18-month preparation, a pilot launched in 2017 with more than 890 patients.