Comprehensive COPD Clinic creates remote patient monitoring program to reduce hospital readmissions

Aiming to improve health outcomes and reduce hospital readmissions, the Comprehensive COPD Clinic at UC Davis Health has created the first remote patient monitoring program in the Sacramento region for high-risk patients with Chronic Obstructive Pulmonary Disease (COPD).

Studies show these patients have a high rate of hospital readmissions. One study found that among Medicare beneficiaries admitted to the hospital for COPD, 19.6% were readmitted within 30 days.

“COPD is a disease that comes in many forms, so treatment needs to be tailored to individual patients and their burden of disease,” said Brooks Kuhn, assistant professor of medicine and co-director of the Comprehensive COPD Clinic. “The core mission of the program is to empower our high-risk patients with health technology tools to help remove barriers to care, emphasize preventive care and improve self-management, which are critical to improving clinical outcomes and patient quality of life.”

Monitoring symptoms remotely with technology

The program enrolls up to 12 patients with COPD at any time, all of whom are given a pulse oximeter, an electronic device that measures the patient's heart rate and saturation of oxygen carried in their red blood cells. The data collected is uploaded to a dashboard on the patient's electronic health record and is monitored daily by respiratory therapists in the Reversible Obstructive Airway Disease program.

Additionally, patients answer one question every day: “Are your symptoms better, worse or staying the same as yesterday?” This is also uploaded to their electronic health record.

“When we developed this program, we wanted to create something that integrated into our electronic health record program,” Kuhn explained. “We also wanted to make sure there was a strong robust clinical backbone behind it and the data we collected was actionable. Combining the data from the pulse oximeter with the patient's symptom data provided us some context.”

Within the dashboard, UC Davis Health’s information technology team members built a series of rules to filter the collected data. The team set up alarms that are triggered when a patient’s symptoms are concerning. Respiratory therapists then reach out to provide care and guidance.

“The goal for our respiratory therapists is to work with patients to identify early signs and symptoms of their COPD exacerbation to avoid unnecessary health care utilization,” explained Krystal Craddock, clinical operations manager for respiratory care. “Each patient has an action plan, and our respiratory therapists lead them through their personalized plan to control their symptoms and get them over that exacerbation hump to prevent the need for readmission to the hospital.”

Building on a culture of innovation

To augment their remote patient monitoring program, UC Davis Health collaborated with Propeller Health to offer additional personalized treatment for high-risk COPD patients.

Eligible patients receive the Propeller remote monitoring program. It includes sensors, a mobile app, web portal, and personalized support. The sensors attach to a patient’s inhaler to capture unique signals that record events, such as medication usage or respiration. This data is transmitted to UC Davis Health’s electronic health record system to support patient enrollment and remote patient monitoring via a single sign-on.

Through the electronic health record system integration, clinicians are able to track a patient’s day-to-day use of their inhalers, allowing them to monitor the use of “everyday medications” that keep the lungs functioning optimally. They’ll also be able to track rescue medications, which are used when the patient is short of breath and needs more help.

“The rescue use is key in alerting clinicians that the patient may be experiencing early signs of a COPD exacerbation,” Craddock explained. “We will then be able to reach out to these patients and treat them early, hopefully avoiding unnecessary emergency room visits or hospitalizations.”

Need for personalized care

According to the Centers for Disease Control and Prevention, 16 million Americans suffer from COPD. The CDC also stated that this number is likely higher as many have yet to receive a diagnosis or treatment.

“There are so many patients in our community that could benefit from a program like this and improve their clinical outcomes,” Kuhn added. “I appreciate the hard work of our amazing interdisciplinary team members, who have been crucial in getting the remote patient monitoring program operational. It allows us to personalize the care we provide our patients to their specific needs.”