The chronic obstructive pulmonary disease (COPD) pathway continues to be successful in reducing COPD 30-day readmissions at Marshfield Medical Center–Park Falls. The pathway was rolled out in January of 2018 after having more than 20 COPD readmissions in 2017. In 2018, this number was reduced to three readmissions. The total cost for COPD admissions averages $20,176.35. With reductions in COPD readmissions in 2017, Flambeau hospital achieved an estimated cost reduction of $342,997.89 in 2018. 
 
The pathway follows a patient with COPD mild/moderate or severe symptoms and addresses respiratory treatments, including oxygen use, medications and home regimens, medication transitions, patient activity, smoking cessation, flu vaccinations, discharge information, post-hospital follow up, use of a dyspnea scale and patient education. This year’s focus was on post-hospital follow-up. For this, a COPD educator follows a COPD patient for several weeks after hospitalization, depending on the patient’s needs and health status. If a patient is stable, they are contacted after one week and then again one month after hospital discharge. More fragile patients are contacted weekly until they are stable. There are also some patients who receive a home visit by the COPD educator, depending on the patient and the severity of their COPD. The outreach and management post discharge are unique and individualized.
 
The COPD educator also works with insurance companies and home care companies to provide patients with special equipment and treatments at home and continues to follow up with patients to make sure lung/respiratory tests are completed so they can qualify for pulmonary rehabilitation services. 
 
The COPD educator also facilitates the very popular COPD community support group, the “Better Breathers Club” that meets monthly. Participants are recruited by the COPD educator who reaches out to COPD patients recently discharged from the hospital. The program is promoted through social media, local papers, radio, and once the core group is established, it is also spread further by word of mouth. 
 
The multidisciplinary approach of the pathway and the post-hospital focus has proven to reduce COPD readmissions at Marshfield Medical Center – Park Falls Hospital, providing best practice care to all COPD patients both in and out of the hospital. The team’s next focus will be to look at incorporating pneumonia into the pathway by adapting it to a respiratory pathway to broaden the scope of the COPD pathway. The COPD educator will also begin to follow pneumonia patients post hospitalization as well.
 
In response to the COVID-19 pandemic, Marshfield Medical Center – Park Falls Hospital is starting to see patients recovering from COVID-19 in the pulmonary rehab department to continue care and reduce the likelihood of a readmission.  Many of the recovering patients have COPD and/or other chronic respiratory conditions, so it is helpful to get those patients in to rehab as soon as possible.

“Flambeau’s ingenuity and innovation to provide special care for their rural community is not just an example for rural health care, it’s an example for the rest of the state. I am proud that we have thought and practice health care leaders like Kim Bortz and her team in my district.”
 - Rep. Beth Meyers (D-Bayfield)
 
“Flambeau Hospital’s achievement in reducing hospital readmissions positively impacts the health care system. Wisconsin’s top-ranking health care is a result of to the collaborative effort of a dedicated team of professionals, and a regulatory environment that allows and encourages innovation. Congrats to Flambeau for being a featured quality project by the Wisconsin Hospital Association!”
 - Sen. Janet Bewley (D-Mason)

View Marshfield Medical Center-Park Falls’ poster detailing this project here.