COPD Insider

Three keys to reducing readmissions of your “frequent flyers”

Learn 3 keys to reducing readmissions for your “frequent flyers”—making their transition from hospital to home more permanent.

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Sometimes hospitals see the same COPD patients readmitted to your ER many times. This group is called “frequent flyers,” these patients continuously struggle to remain healthy in their homes, creating a constant battle for hospitals. It has never been more urgent to innovate ways to manage these patients at home for fewer readmissions and greater long-term gains. With so many opportunities for these patients to end up back in the ED, it’s vital to have a clear plan to not only identify frequent flyers but to make their transition from hospital to home a more permanent one.


You have questions, our experts have answers. Discover the three keys needed to reduce readmissions of your frequent flyers and set them up for sustainable success.


Becky Anderson

Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Center

Les Duncan

Les Duncan

Director of Operations

Highmark Community and Health Services

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Identify the root cause behind a frequent flyer’s readmission


The first step is to identify why some patients are spending more time in your ED. Through discussions about their symptoms, therapy devices and their current treatment plan, your team should be able to recognize surface-level issues that contribute to their readmissions. But to make a significant impact, you need to get to the root cause of why these patients are readmitting in the first place.


According to Les Duncan, Director of Operations at Highmark Community and Health Services, behavioral health is a huge issue among frequent flyers. For them, the ED may be a social outlet or a safe place. They know that when they’re admitted, they get professional attention, their medications, a bed to sleep in, meals and more.


With statistics showing that COPD patients with depression are nearly three times more likely to be readmitted in one year, addressing mental health issues is a critical step to prevent constant readmissions.1

Learn how deepening your mental health focus can elevate the care you provide.
Becky Anderson video

Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Center

Ask the right questions to set up the right care plan


By asking questions like these, you can make all the difference:


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“What kind of support is available for you?”
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“Do you currently have a home care plan in place?”
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“What is your living situation?”
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“Do you have access to basic necessities?”
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“Is anyone else suffering from an illness? Are you their caretaker?”
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Establish clear communication throughout your care team


To reduce readmissions in frequent flyers, your care team needs to be communicating openly about those patients’ profiles, history and goals. From nurses to pulmonologists, establishing seamless integration throughout the entire patient journey will help prevent communication breakdowns. It will also support your team in sharing key insights for better overall care.

Establishing clear communication can help:

  • Ensure each team member has universal knowledge of the patient’s case
  • Analyze the systemic breakdowns that may be causing readmissions
  • Provide the education and therapies patients need to minimize exacerbations and maximize success
  • Deliver consistent and continuous care from when a frequent flyer is admitted to when they return home
  • Involve DME providers to perform an in-home visit and provide a frequent flyer with a device that is suited to their cognitive and physical capabilities

Discover the key individuals you should include in your COPD care team to successfully reduce readmissions.

Les Duncan

Director of Operations

Highmark Community and Health Services

Les Ducan video
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Don’t wait to implement readmission reduction programs


To combat frequent readmissions, you need to put programs in place that you and your care team believe in. But operationalizing a successful solution doesn’t happen overnight. According to Les Duncan, “You have to start and figure it out as you go.”

Here are some suggestions for getting started:

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Review the current programs your institution already has in place. Don’t limit it to just your department—expand your review to look at programs across other service lines
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Perform a thorough analysis of these programs. Figure out what works, what could be improved and how to tailor them to your needs and the needs of your patients
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Take the best solutions and incorporate them into your department. Avoid getting caught up in discovering the perfect solution or navigating your way through the layers of red tape. Decide what you believe to be the best practices, carry them out and commit 100%. You’ll have plenty of opportunity to refine your program down the road
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Invest in home care to support health for less cost


Home care programs have been shown to2:


  • Reduce readmissions
  • Reduce the total amount of days a patient is readmitted
  • Improve quality of life
  • Improve patient satisfaction after discharge
A $100 home visit offsets a $10,000 inpatient visit.”

Les Duncan

Director of Operations, Highmark Community and Health Services

Find out how shifting patients from hospital to home can reduce readmissions and cut costs in the process.
Les Ducan video

Case study: Hear how insider Les Duncan created a program to track frequent flyers and break the cycle of readmissions

Les Duncan

Director of Operations

Highmark Community and Health Services

Focus on frequent flyers and watch readmissions drop


Reducing readmissions, especially in complex patients, is clearly a challenge. But the longer you wait to put solutions in place, the longer you postpone success. That’s why it’s important to focus on these cases and see each challenge as an opportunity to support better outcomes. By identifying the root cause of a patients’ readmissions, establishing clear lines of communication and implementing readmission reduction programs, you may just make a frequent flyer’s move from hospital to home a permanent one.

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1. Iyer AS, Bhat SP, Garner JJ, et al. Depression is associated with readmission for acute exacerbation of chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2016;13(2):197-203.

2. Krishnan JA, Gussin HA, Prieto-Centurion V, Sullivan JL, Zaidi F, Thomashow BM. National COPD readmissions summit 2013: integrating COPD into patient-centered hospital readmissions reduction programs. Chron Obstruct Pulm Dis. 2015;2(1):70-80.

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