Why every COPD patient needs a case manager

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Managing the best interests of the patient as a whole

All medical professionals have the best interests of their patients at heart, but with so many moving parts and so many different individuals involved in patient care, it’s easy for things to fall through the cracks. Having a case manager is critical to addressing that problem. By ensuring continuity across care settings, case managers give patients the care they deserve at every step of the process.

You can have a world-class care team, but without the connective tissue a case manager provides, you multiply the risk that a gap in care will lead to a readmission. It’s an invaluable investment that supports better outcomes for all.

The MVPs of your care team, no matter what you call them

According to the Case Management Society of America, “case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care and cost-effective outcomes.”¹

Case managers go by a variety of names and titles, depending on the institutions they work for.

“We've heard COPD coordinator, we've heard COPD educator, we've heard COPD disease manager, and more recently, COPD case manager,” says Vernon Pertelle.

No matter what you call them, case managers have one thing in common: They’ve been credentialed through an official certifying body like the American Case Management Association, the Commission for Case Manager Certification or the American Nurses Credentialing Center.

Regardless of their backgrounds—whether they’re a registered nurse, a respiratory therapist, a social worker, or something else entirely—or their official titles, a certified case manager is often the missing piece in maximizing COPD outcomes.²

Contributors

Roberto Benzo, MD, MSc

Motivational Based Health Coaching

Krystal Craddock, BSRC, RRT-NPS, AEC

COPD Case Manager

Department of Respiratory Care at UC Davis Medical Center

Keith T. Kanel, MD, MHCM, FACP

Clinical Associate Professor of Medicine University of Pittsburgh

Vernon Pertelle, RRT

President and CEO

StratiHealth

Management Consultant for ACOs

We've heard COPD coordinator, we've heard COPD educator, we've heard COPD disease manager, and more recently, COPD case manager”

Vernon Pertelle, RRT

President and CEO

StratiHealth

Management Consultant for ACOs

Let’s take a deeper look at a case manager’s distinctive value—and why every patient should have one.

A case manager provides frontline education and engagement

People feel reassured that somebody cares.”

Roberto Benzo, MD, MSc

Motivational-Based Health Coach

By educating patients and getting to know them, case managers can help patients stay informed, cope with their situation and drive change in a patient’s lifestyle at home to help them avoid exacerbations.

“I believe that if you just focus on the patient and provide them with the best education, and sit down and provide empathy, if you do all of that, and you really commit to doing it and you do it with passion, that the numbers follow,” says Krystal Craddock, a COPD case manager. “The readmission rates will come down if we all just come together to treat the patient.”

On what makes a good case manager

⮟

You need someone who is really driven to want to help the patient manage their disease at home and to help improve quality of life. Not just saving a life at that moment. You're really thinking about what's going to happen to the patient after they leave the hospital. You need someone who's caring, who wants to take their time at the bedside with the patient. Talk about their home life, their social issues, their family support, and recommend patients for outpatient pulmonary rehab, different support groups for that patient to help not only treat their disease with medications but also get them out of the house. Get them breathing better, get them exercising, and really that social aspect helps with their spirits and helps them feel better as well.

Krystal Craddock, BSRC, RRT-NPS, AE-C, CCM

COPD Case Manager

UCal Davis

“Patient engagement is critical,” says Roberto Benzo, a motivational-based health coach. “It's a missing piece sometimes in the decision making. We need, of course, a proper treatment, we need a proper professional, but we need the patient, because at the end of the day, all changes happen in the patient’s home.”

If a patient isn’t properly educated or isn’t in the right state of mind to make wise lifestyle choices, you run a high risk of seeing them back in the hospital sooner rather than later.

Insider insight: The prevalence of COPD readmissions⁴

According to an analysis of the Nationwide Readmissions Database:

19%

of COPD exacerbation patients are readmitted within 30 days

4.2% - 5.5%

are readmitted within 72 hours of discharge

58%

of readmissions occur in the first 15 days

A case manager has the knowledge needed to personalize care

After truly getting to know a patient and the details of their condition, who better to oversee their care journey than the case manager? A case manager becomes an expert on the specifics of each patient’s situation, and as a result, they’re best suited to coordinate care and advocate for that patient from start to finish.

Many COPD patients are dealing with other medical issues in addition to COPD. In fact, studies have found that nearly 70% of COPD patients suffer from comorbidities that require multiple types of treatment.⁵ Case managers can serve as a liaison among different members of the care team to coordinate those varying treatments—ensuring that everything is properly addressed and that treatments or medications don’t conflict or negatively interact.

Without the presence of a case manager, there’s a greater risk of fragmented, ineffective care.

“We're not just focusing on their COPD, we're looking to see if they also have heart failure, we're having a pharmacist coming to the bedside and going over all their medications. The case manager will teach the patient about their disease and how to use their inhalers and get them on the right things,” Craddock says. “Bringing all of these once-siloed disciplines together to help manage the patient as a whole is really what improves outcomes.”

Every patient can benefit from a case manager, but who makes for the best case managers? Nurses or respiratory therapists?

A case manager facilitates the transition home and follows up to make sure patients stay on track

Start your own COPD case manager program

Investing in a case manager initiative at your institution might seem like a monumental task, but it’s an undertaking that will undoubtedly pay off in the long run. The key, according to Craddock, is to start small.

“We started with seeing patients who were in for COPD who could really be involved in the bedside education,” Craddock says. “So our severe psychiatric patients, our patients going through drug withdrawals, we weren't seeing at first, because we really wanted to figure out the program before we expanded it to everyone. After figuring out what worked and what didn't work and what we needed to change, then we started seeing all patients with COPD and treating them equally, and we've shown great outcomes with it.”

This level of focused care will help make a dramatic difference for patients and your institution.

Insider case study: Implementing a case manager program University of California Davis Medical Center

The problem:

High burden of COPD care

16% COPD readmissions rate
7.5-day average length of stay

The plan:

UCal Davis received a $160,000 grant to implement a case manager program in an attempt to reduce COPD readmissions. Eight UCal Davis respiratory therapists began training for case manager certification. Their training included weekly two-hour classes with their medical director and pulmonologist as well as a COPD educator course through the American Association of Respiratory Care. The respiratory therapists learned about things like motivational interviewing, health literacy, and GOLD guidelines.

The problem:

High burden of COPD care

16% COPD readmissions rate
7.5-day average length of stay

The problem:

High burden of COPD care

16% COPD readmissions rate
7.5-day average length of stay

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References

1. What is a case manager? Case Management Society of America. http://www.cmsa.org/who-we-are/what-is-a-case-manager. Accessed March 18, 2019.

2. Case managers: keys to maximizing COPD health outcomes. COPD Foundation. https://www.copdfoundation.org/Praxis/Community/Blog/Article/532/Case-Managers-Keys-to-Maximizing-COPD-Health-Outcomes.aspx. Accessed March 18, 2019.

3. Stage KB, Middelboe T, Stage TB, Sørensen CH. Depression in COPD—management and quality of life considerations. Int J Chron Obstruct Pulm Dis. 2006;1(3):315-320.

4. Jacobs DM, Noyes K, Zhao J, et al. Early hospital readmissions after an acute exacerbation of chronic obstructive pulmonary disease in the Nationwide Readmissions Database. Ann Am Thorac Soc. 2018;15(7):837-845.

5. Anecchino C, Rossi E, Fanizza C, De Rosa M, Tognoni G, Romero M. Prevalence of chronic obstructive pulmonary disease and pattern of comorbidities in a general population. Int J Chron Pulmon Obstr Dis. 2007;2(4):567-574.

6. van Eeden AE, van de Poll I, van Vulpen G, et al. Effectiveness of case management in the prevention of COPD re-admissions: a pilot study. BMC Res Notes. 2017;10:621.

7. Alshabanat A, Otterstatter MC, Sin DD, et al.; on behalf of the COPD Transition Team Program. Impact of a COPD comprehensive case management program on hospital length of stay and readmission rates. Int J Chron Pulmon Obstr Dis. 2017;12:961-971.

All content on this site is for informational and educational purposes only and is not a substitute for medical advice of your doctor or other health care professional. Always seek the advice of your physician or other health care provider with any questions you may have about any medical condition. Refer to the Terms of Use for additional information.

Why every COPD patient needs a case manager

Share this story

Share this story

Managing the best interests of the patient as a whole

The MVPs of your care team, no matter what you call them

Contributors

Roberto Benzo, MD, MSc

Krystal Craddock, BSRC, RRT-NPS, AEC

Keith T. Kanel, MD, MHCM, FACP

Vernon Pertelle, RRT

Vernon Pertelle, RRT

Let’s take a deeper look at a case manager’s distinctive value—and why every patient should have one.

A case manager provides frontline education and engagement

Roberto Benzo, MD, MSc

On what makes a good case manager

⮟

Krystal Craddock, BSRC, RRT-NPS, AE-C, CCM

Insider insight: The prevalence of COPD readmissions4

19%

of COPD exacerbation patients are readmitted within 30 days

4.2% - 5.5%

are readmitted within 72 hours of discharge

58%

of readmissions occur in the first 15 days

A case manager has the knowledge needed to personalize care

A case manager facilitates the transition home and follows up to make sure patients stay on track

Start your own COPD case manager program

Insider case study: Implementing a case manager program University of California Davis Medical Center

The problem:

The plan:

The problem:

The problem:

Register now for exclusive monthly content like this delivered directly to your inbox

Contact information

Contact details

Company details

Further reading

COPD insider

Insider insight: The prevalence of COPD readmissions⁴