Running head: EXECUTIVE SUMMARY

Executive Summary
Everyday Management for Chronic Obstructive Pulmonary Disease (COPD)
Melissa Ritchey
The University of Arizona

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Introduction
Desert Regional Healthcare Alliance (DRHA) is a community medical center that is
dedicated to expanding its services to focus on care coordination. Chronic obstructive
pulmonary disease (COPD) is the third leading cause of death in the United States and
contributes to the majority of the readmissions at DRHA. It is essential to manage the care of a
COPD patient from the hospital to their everyday home life to increase their quality of life,
decrease exacerbations and prevent an avoidable readmission to the hospital. Due to the
significant needs of this patient population, this development team has created a proposal for a
pilot project to coordinate the care for patients that meet the referral criteria to the COPD clinic.
Care Coordination Program and Delivery of Services
The COPD clinic will be located across the street from DRHA at a rehabilitation clinic.
A referral tool has been established and a Case Manager at DRHA can refer the patient to the
COPD Everyday Management Clinic. The program will be managed by Nurse Practitioner (NP)
with the assistance of a Health Coach (HC), a Respiratory Therapist (RT) and a Medical
Assistant (MA). The nurse managed health clinic (NMHC) model allows the NP to complete an
initial assessment and perform a medication reconciliation of the patients medications. The NP
will then form an individualized plan that the HC will review with the patient and help the
patient adopt the plan to help them manage their illness at home and make the necessary lifestyle
changes. The RT will assist with any inhaler teaching, perform lung function tests, teach the
patient how to monitor vital signs and also will conduct a one hour group session in collaboration
with the American Lung Association (ALA). The patients will be provided with the necessary
equipment they need to monitor their vital signs at home. The Betters Breathers Club, will be
a support group in which the RT assists with smoking cessation proper breathing techniques and

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provide support for the patients who are experiencing a life changing event. The patients will be
responsible for filling out daily assessments and measuring their vital signs at home, they will
input the results into an electronic health record called My Chart. Depending on the responses
the inputted by the patient into the My Chart system, a score will be generated and will alert
the Everyday Management of COPD program staff if the patient is in danger. There will also be
a tool assigning the patient a color for that day. The red (bad day), yellow (medium day), or
green (great day) will indicate whether the current treatment plan and regimen are working
correctly for the patient. When there are three or more yellow days in the same week, the "My
Chart" system will prompt the clinic to call the patient and determine if the patient requires a
follow-up. If there are two or more red days within the same week, the "My Chart" system will
prompt the clinic to call the patient and inform him/her to come in to be seen by the NP. The
"My Chart" will be adjusted for each of the patients needs and goals to maintain a healthy and
functional lifestyle while living with COPD.
Benefits to Target Population
Symptoms of COPD include constant coughing, excess sputum production, dyspnea and
wheezing. COPD can affect a persons quality of life because the most basic tasks become
difficult to do because of the severe shortness of breath. The Everyday Management Clinic will
provide the patient with a dedicated team to manage their illness, teach the patient to manage
their own disease, make changes to their lifestyle and be responsible for their own outcomes.
The team will have measures in place to alert them if the patient needs additional follow up or
emergent care to prevent a delay in care. The weekly support groups will be critical in
measuring the needs of the patient and their family and also to provide them with the support
they need when managing a life altering illness.
Finances for Program

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The COPD Everyday Management program has established a budget that will not exceed
$250,000 in operating expenses for 2015 and 2016. The clinic will be set up at rehabilitation
clinic owned by DRHA eliminating the need to rent a space acquiring capital expenses. The NP,
HC, and RT are employees of DRHA and will be paid an hourly rate to minimize the expense to
the clinic in benefits and guaranteed hourly salaries. The nurse managed clinic allows the NP to
bill for a transitional care charge to continue funding the clinic. Although the clinic will not
generate a large amount of money, the return on investment is in the prevention of readmissions
decreasing the costs the hospital is currently acquiring in readmission rates.
Projected Outcomes and Benefits to the System
The patient and their family will be the focus of the clinic. The goal is to enhance the
patients quality of life, teach them to successfully manage their COPD at home, and provide
them with a monitoring system to assure they receive urgent or emergent care in a timely
manner. DRHA will benefit by reducing the cost of current readmissions to the hospital. The
goal is to decrease the 30 day readmission rate from 37% to 16% with a potential savings of up
to $260,000 a month. The program would pay for itself year after year and continue to allow
DRHA to do the right thing for these patients and perhaps expand to other patients with chronic
illnesses. In conclusion, providing a NMHC, health coach, support groups and access to My
Chart to high risk patients after discharge can reduce the amount of avoidable readmissions and
provide an economical solution to managing high risk patients after discharge from a hospital
setting.

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