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How proactive planning can

get patients home—and keep them home


It takes more than just a good treatment plan and a prescription to keep your patients healthy at home. Follow one patient’s journey from discharge to readmission and learn how taking a proactive approach to care can safeguard against this from happening again.

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Keeping patients home begins before they leave your facility

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Name: Jane


Admitted: 5/3


Discharge Date: 5/6


Readmission Date: 6/3




  • Treatment plan and prescription for oxygen was handed to patient on discharge date above
  • No education or training on device that was provided
  • Goal-setting was not completed
  • No follow-ups with patient were attempted
  • Patient was readmitted with complications from COPD symptoms


Portrait of Becky Anderson

Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Center

Portrait of Jennifer Anderson

Jennifer Anderson, MBA, RRT, AE-C

Director Respiratory Care and Pulmonary Function Labs

AU Medical Center

Portrait of Brain Carlin

Brian Carlin, MD, FCCP, FAARC

Critical Care Staff Physician

Altoona Regional Health System

For patients with COPD like Jane, this is exactly what shouldn’t happen. Handing them a treatment plan and a prescription without anything else may be setting your patients up for a trip back to your emergency department. Patients with COPD need more than this to keep them healthy at home.


The good news—we’ve got you covered. Let’s take a glimpse into the month between Jane’s discharge to her readmission and how you can take a proactive approach to care to help all your patients with COPD live the healthy life they want to live at home.

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Do: Engage your patients from the start

A longitudinal, proactive approach to care can support keeping patients like Jane healthy at home. This means focusing on what your patients want and getting ahead of their disease. To meet these goals, constant engagement is key.


According to Jennifer Anderson, a good place to start is by asking your patients about what they desire out of treatment and out of life. Find out what their pain points are, what would make adherence to treatment easier, and what goals they want to achieve. This level of understanding may help strengthen the patient-physician relationship and help you set up a personalized, patient-influenced treatment plan.


Our expert panel also says that the lines of communication shouldn’t stop after this initial conversation. Engagement should be consistent throughout the entire continuum of care. Whether it be weekly follow-up phone calls or in-home visits from a member of your care team, patients need to feel supported and know that you are invested in their treatment goals. 



Schedule regular in-home visits with durable medical equipment (DME) providers and respiratory therapists (RTs)


DMEs and RTs can lead patients to more effective care by helping them1:

Stripe image 1: Choose a device that fits into their life
Stripe image 2: Train them on proper utilization of their device
Stripe image 3: Ensure their device is working efficiently

On the need to communicate with patients

Still from the video 'On the need to communicate with patients'

Jennifer Anderson, MBA, RRT, AE-C

Director Respiratory Care and Pulmonary Function Labs

AU Medical Center

A good tool to promote engagement is to implement a self-management support program. Self-management support programs include a COPD exacerbation action plan, professional follow-up phone calls, and education materials that have been shown to reduce2:

Hospitalizations icon
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ER visits icon
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Unscheduled physician visits icon
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Do: Set actionable and achievable goals

Once you’ve uncovered your patient’s story, it’s time to set goals. These goals should be meaningful, actionable, and achievable. When setting goals, it’s important to ensure they’re something your patient wants.


For example, say you set a goal for Jane of increasing her adherence to therapy. While this is a good clinical goal, it may not necessarily be meaningful to her. Instead, allow Jane to set a personal, meaningful goal. Whether it’s going for a daily walk, getting back to gardening, or joining her family on vacation, this goal should mean something to her.


Once she determines her goal, let her know that the action she needs to take to meet this goal is to increase her adherence to therapy. This way Jane knows what needs to be done to achieve her goal. 

Gauge your patients confidence before you both set a potentially unachievable goal

Ask your patients, “On a scale from 1-10, how confident are you in achieving this goal?” For an achievable goal, their answer should fall between 7 and 10.

Image of patients gauging level goals
1 to 3 not confident at all image
4 to 6 somewhat confident image
7 to 10 confident image. I know I can meet this goal
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Do: Find a device that fits into their life

Once an achievable goal is set, it’s important to anticipate their needs for a device—but not just any device, one that integrates as seamlessly as possible into their life.


When planning for a device, a good first step to is to put yourself in their shoes. Schedule a home visit. Follow them throughout their day. Discuss which device will help them live the life they want without getting in the way. By involving patients like Jane in this decision, they may feel more comfortable with their device and gain a better understanding of the benefits that come along with it.3

But, finding the right device is only part of the equation. For patients to remain healthy at home they should be educated and trained repeatedly on the device they’ve been prescribed.According to Brian Carlin, MD, FCCP, FAARC, setting up programs that involve a DME provider and respiratory therapist in a home visit may help educate the patient on various devices that are available to them as well as what the device does.

On the need to involve care

team members

On the need to involve care team members!

Still from the video 'On the need to involve care team members'

Patients should be educated and trained repeatedly 


A retrospective study showed that almost 54% of patients stopped their medications periodically over a 3-month period when they only received education and training during their initial visit.4

People with chronic disease should be

living well in their homes. They shouldn’t be

in and out of our EDs.”

Becky Anderson, RRT

Manager, Respiratory Care Services

Sanford Medical Center

Plan to get and keep patients home today


The days of giving patients like Jane a good treatment plan and sending them on their way are over. It takes much more than that to get and keep them healthy at home. But spending a little more time getting to know your patients goes a long way.


Engage them fully, uncover their story and goals, find a device that integrates into their life and watch their success story unfold.

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Further reading

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COPD insider


1. Diiulio R. DME: Oxygen Therapy Caregivers, Not Just Equipment Suppliers. RT Magazine Web site. http://www.rtmagazine.com/2015/04/dme-oxygen-therapy-caregivers-just-equipment-suppliers/. Published April 3, 2015. Accessed April 4, 2017.

2. Fromer L. Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes. Int J Chron Obstruct Pulmon Dis. 2011;6:605-614.

3. Sanduzzi A, Balbo P, Candoli P, et al. COPD: adherence to therapy. Multidiscip Respir Med. 2014;9(1):60.

4. Bonini M, Usmani OS. The importance of inhaler devices in the treatment of COPD. COPD Res Pract. 2015;1:9.

5.  Singh G, Zhang W, Kuo YF, Sharma G. Association of psychological disorders with 30-day readmission rates in patient with COPD. Chest. 2016;149(4):905-915.

6. Pratt LA, Brody DJ. Depression and smoking in the U.S. household population aged 20 and over, 2005-2008. NCHS Data Brief. 2010;(34):1-8.

7. Iyer AS, Bhatt 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.

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