presented by Kenneth L. Miller, Rebecca Crouch & Ellen Hillegass
Readmission to the hospital for patients with COPD is a national concern. It is a problem for hospitals because it comes with a penalty from CMS if the readmission occurs within 30 days of discharge. Patients with COPD require monitoring beyond the acute care setting, and the current evidence supports continued monitoring of these patients beyond the acute care setting and the acute exacerbation. However, transition from the acute care setting to the home (or outpatient setting) is not always smooth, and communication is often lacking. This course will discuss the problem of readmission and transition of care, as well as the patient with COPD who is treated in the acute care setting and moves to the home setting. The identification of COPD patients at high risk for readmission will be discussed, along with the medications the patients may be sent home with and best practice for care in the home and outside the hospital.
Dr. Kenneth Miller has been an educator, physical therapist, and consultant for the home health industry for more than 20 years and serves as a guest lecturer, adjunct teaching assistant, and adjunct professor in the DPT program at Touro College in Bay Shore, New York. He has presented at the Combined Sections Meeting of the American Physical Therapy Association (APTA), the Educational and Leadership Conference of the American Council of Academic Physical Therapy and Education Section of the APTA, and the Annual Conference of the National Association for Home Care and Hospice on a variety of topics, including objective testing, professionalism, interdisciplinary team modeling, osteoporosis, differential diagnosis of dizziness, documentation, patient engagement, student program development, and home health regulations. He serves as chair of the Practice Committee of the Home Health Section (HHS) of the APTA. As the chair, he led the development of the "Providing Physical Therapy" section in the third edition of the home handbook, the Home Health Student Program Roadmap & Toolkit, and The Home Health Section Toolbox of Standardized Tests & Measures. He is a member of the editorial boards of the GeriNotes publication and of the Journal of Novel Physiotherapy and Physical Medicine, and is a manuscript reviewer for the Journal of Geriatric Physical Therapy and the Journal of Primary Care. Dr. Miller has authored numerous articles for the Journal of Geriatric Physical Therapy, GeriNotes, and the HHS newsletter, The Quarterly Report.
Dr. Rebecca Crouch has practiced cardiovascular and pulmonary physical therapy in the acute care and outpatient rehabilitation settings, and was a founding member and director of the Duke University pulmonary rehabilitation outpatient program for 30 years. She is now an assistant professor in the Doctor of Physical Therapy program at Campbell University, and her clinical practice is in acute care at Duke. She has written numerous publications and given presentations in the areas of pulmonary rehabilitation, oxygen management for physical therapists, evaluation and exercise for the cardiopulmonary transplant and medical pulmonary populations, and outcomes measurement. Dr. Crouch has been involved in several professional organizations, including the American Physical Therapy Association (Cardiovascular and Pulmonary Section), American Thoracic Society (state and national), and the American Association of Cardiopulmonary Rehabilitation and Prevention. Dr. Crouch is a business partner in PT Cardiopulmonary Educators, a webinar-based educational service, and is CEO of Cardiopulmonary Therapy Resources, a cardiopulmonary consulting business.
Dr. Ellen Hillegass is a physical therapist with APTA board certification in cardiovascular and pulmonary clinical specialty. She currently holds the position of adjunct professor in the departments of physical therapy at Mercer University in Atlanta and Western Carolina University in Cullowhee, NC. Ellen is also the president and CEO of Cardiopulmonary Specialists, a private consulting firm that provides consulting and education on cardiac and pulmonary rehabilitation. Additionally, she is a partner in PT Cardiopulmonary Educators, a web-based education company for entry-level DPT, residency, CCS board preparation, and continuing education. She also presents courses across the country on early mobility. She has been active in the cardiovascular and pulmonary section for many years and is the former Payment and Policy chair for the cardiovascular and pulmonary section. She has represented the cardiovascular and pulmonary issues of physical therapists at the Centers for Medicaid and Medicare Services along with the APTA on several occasions. Dr. Hillegass started a clinical residency through Mercer University in conjunction with Piedmont Hospital and works with the residents in the ICUs on a weekly basis. Her first resident was recently awarded their CCS this past February at the APTA CSM meeting in San Antonio, where two former residents presented their research as well (one on walking IABP and one with a poster on early mobility). Ellen Hillegass is a member of the Board of Directors of the US COPD Coalition, as well as the chair of the COPD Coalition Strategic Planning Committee. She was the chair of the Clinical Practice Guidelines Committee on Venous Thromboembolism for the APTA (published in Physical Therapy journal in Febrary of 2016), and is the past chair of the Oxygen Recommendations Task Force for the APTA. She is a Catherine Worthingham fellow of the American Physical Therapy Association. She is the editor of Essentials in Cardiopulmonary Physical Therapy, an entry-level text with its fourth edition published in June 2016, as well as the author of a clinical notes book entitled PT Clinical Notes (formerly Rehab Notes). Ellen received her entry-level training in physical therapy from the University of Pennsylvania, her Master of Medical Science in Cardiopulmonary Physiology from Emory University, and her doctorate in Exercise Physiology from the University of Georgia. Her dissertation involved muscle morphology in the spinal-cord injured patient.
CMS has started to penalize hospitals for patients with COPD who are readmitted within 30 days of discharge. Therefore, hospitals have been searching for ways to prevent readmissions. Identifying high-risk patients and developing post-hospital transition programs have become the norm to assist with decreasing readmissions. The evidence on predictors of readmission is discussed; this evidence lays the foundation for this course.
The physical therapist must be familiar with the typical pathophysiological characteristics and presentation of the COPD patient. Common tests used for COPD diagnosis are adequate to detect moderate to advanced disease but may not be specific enough to detect early stages of COPD. Common medications exist for the relief of symptoms of COPD, but there are no known curative or preventive medications.
Starting with the case of a patient with an acute exacerbation, discussion centers around the treatment of the patient while an inpatient, including the medical management and physical exercise needed. This section discusses the inpatient experience, up to and including the discharge expectations.
Supplemental oxygen is known to improve survival and quality of life in patients with significant resting and exercise hypoxemia. The benefit of supplemental oxygen is less clear for those with minimal to moderate hypoxemia at rest or with exercise. New evidence addressing oxygen supplementation will be discussed.
Many patients discharged home from an acute hospital admission for COPD have exacerbations that are not fully resolved at the time of discharge, which increases the risk of rehospitalization. Transitioning home is a vulnerable time point that requires appropriate handoff of information between practice settings and the patient. Coaching, discharge management, and patient self-management are key to reducing readmissions.
Patient engagement and activation to increase adherence to medication regime, physical activity, smoking cessation, and self-monitoring for decompensation are best practices to reduce re-hospitalization risk. Providing education in self-management of medications, including oxygen and activity level will be explored to reduce rehospitalization risk. Providing education in self-management of medications (including oxygen) and activity level to reduce rehospitalization risk will be explored.