Purpose/Objectives: Exacerbation and frequent rehospitalization in chronic obstructive pulmonary disease exacts a heavy toll on the US health care system. To address these issues, new initiatives have been proposed that are largely based on financial penalties to promote patient education and postdischarge care. However, as laudable as these goals are, improving outcomes in the chronic obstructive pulmonary disease population is more confounding than it may first appear. Chronic hypoxia, cognitive dysfunction, poor nutrition, and economic disadvantage are just a few of the challenges that require creative solutions and ongoing support. Case managers need to utilize all the potential products and services that can assist in improving outcomes for these patients. Durable medical equipment providers are often viewed as purveyors of medical equipment that offer little in the form of clinical support. However, in many cases these providers represent an overlooked resource that provides individualized, highly structured patient education and ongoing support programs. The challenge is in identifying those durable medical equipment providers that offer patients contemporary technology, and have both the resources and the commitment to provide patient support that is amenable to the goals of the hospital. This article reviews many of the confounding issues that contribute to the frequent rehospitalization of chronic obstructive pulmonary disease patients. Recommendations to improve patient education and oxygen therapy outcomes are provided along with suggestions to aid in the vetting of durable medical equipment providers.

Primary Practice Setting: Acute care hospitals, long-term acute care hospitals, extended care facilities, integrated delivery systems.

Implications for Case Management Practice:

1. An understanding of the complex variables that play in the management of chronic obstructive pulmonary disease will help the case manager to plan an effective course of care.

2. Case managers need to ensure that patients receive long-term oxygen technology that supports their lifestyle, promotes compliance, and ultimately achieves the desired outcomes.

3. Case managers must advocate for coordinated, ongoing patient education and stress the need for continuing reinforcement.

4. Case managers must ensure that patients under their care be matched with durable medical equipment providers that provide the technology and support that favors positive clinical outcomes.

These newer oxygen systems are much smaller, lighter, and less obtrusive than those that have traditionally been furnished and they possess the ability to provide patients with an unlimited supply of portable oxygen.

Technology

Within the past decade new technologies have emerged that improve how LTOT is provided and may promote more frequent oxygen supported ambulation. What these technologies have in common and what makes them superior to previous home oxygen systems are the design features that make them more compatible with patients' lifestyles. These newer oxygen systems are much smaller, lighter, and less obtrusive than those that have traditionally been furnished and they possess the ability to provide patients with an unlimited supply of portable oxygen. Moreover, doing away with portable cylinder deliveries eliminates the need for the patient to remain at home waiting for those deliveries. These technologies, collectively referred to as oxygen-generating portable equipment (OGPE), include patient operated cylinder transfilling systems and both portable and transportable oxygen concentrators. Cylinder transfilling systems let patients fill their own portable oxygen cylinders from oxygen generated by an oxygen concentrator. Portable oxygen concentrators are smaller, lighter versions of the larger stationary models typically seen at home; however, they differ in that they administer oxygen on an intermittent, pulse-dose fashion, instead of providing a continuous flow of oxygen. Transportable oxygen concentrators are new hybrid devices that are slightly larger than their portable cousins, but they are capable of providing oxygen on a continuous flow basis and they offer a degree of portability that the larger traditional stationary concentrators cannot.

Given the clinical advantages afforded by these newer technologies it would seem reasonable to assume that they are used by all DME providers. Unfortunately that is not the case. The reasons why some DME providers are reluctant to transition to these technologies are often financially based. OGPE is more costly to purchase compared to traditional oxygen systems, yet Medicare reimbursement is only slightly higher than that for the traditional stationary oxygen concentrator and delivered portable cylinders. Also, many DME providers have made very significant investments in an inventory that supports the traditional model and they are reluctant to change. These issues are further compounded by the new Medicare cap on payments for home oxygen (payments limited to 36 of 60 months), and an anticipated 30%-40% payment reduction resulting from a Centers for Medicare and Medicaid Services program that requires DME providers to bid for the right to service Medicare beneficiaries (National Competitive Bidding). Despite the financial obstacles that caused some DME providers to shun OGPE technologies many others have embraced it out of recognition that their delivery costs can be reduced as well as an altruistic desire to benefit their patients.

Challenges of Training COPD Patients

Favorable readmission outcomes can be achieved through patient education and sustained reinforcement. Clearly, patient education and training needs to start in the hospital; however, training cannot stop there. To be successful in reducing readmissions, training needs to be continued and reinforced at home. In fact, home may be the best location for training, because it presents with countless opportunities to address real-life scenarios. It seems reasonable to assume that a patient who has been discharged from the hospital is clinically more stable and home may be better suited, both from a physical and emotional perspective, for effective training.

Favorable readmission outcomes can be achieved through patient education and sustained reinforcement. Clearly, patient education and training needs to start in the hospital; however, training cannot stop there. To be successful in reducing readmissions, training needs to be continued and reinforced at home. In fact, home may be the best location for training, because it presents with countless opportunities to address real-life scenarios.

DME providers that offer clinical services employ licensed respiratory therapists or other licensed clinicians to provide patient education; however, not all DME providers do this. Under the Medicare benefit DME companies are not recognized or paid for providing any form of professional clinical services-including patient education. However, the costs of employing these more expensive personnel had historically been offset by the reimbursement provided for the oxygen equipment. Unfortunately, a growing number of providers are considering or already have either reduced or eliminated their clinical staff in response to the considerable cuts in Medicare reimbursement that have taken place. This may not bode well for hospitals looking to reduce COPD patient readmissions. For hospitals to be successful in this effort they need to communicate their expectations to their DME suppliers, including the need for continuing educational support. They also need to evaluate their DME providers to ensure that they are capable of providing the educational services and any other support needed to achieve favorable patient outcomes. As the front line troops in the effort to reduce readmission rates case managers need to vet the DME providers to ensure they have the resources and dedication to support those efforts.

Case managers are responsible for the majority of referrals that DME providers receive. These providers realize that current and future business is largely dependent on meeting the expectations and requirements that their referral sources set. By asking questions and focusing discussion on clinical services and expectations, case managers can send a powerful message to their DME providers: that clinical services and patient education must be preserved, or enhanced.

Identifying Supportive DME Partners

Pressure is mounting throughout the health care system to ensure quality patient outcomes while simultaneously reducing costs. To accommodate these unprecedented changes we must adapt the way oxygen patients are referred to DME providers. As a previous DME provider, it was my experience that the criteria for receiving referrals was often based more on the subjective referral experience and less on the products and services we provided to the patients. Patient referrals can no longer be based on such ambiguous, superficial criteria. In fact, given the recent draconian reductions in oxygen reimbursement one could argue that the only way that DME providers can afford to spend resources to curry favor with their referral sources is through reductions in service, support, or care to the patient. The current market requires true collaboration between case manager and DME provider, with the primary goal of providing quality patient care and service that is measured by improved outcomes and reductions in readmissions. Patient referrals must be predicated on what the DME provider can offer to the patient, not the referral source.

Successfully reducing COPD readmissions requires case managers to align themselves with DME providers that are committed to patient care. The challenge is in seeing past the smoke-and-mirrors to clearly identify the providers who are dedicated to patient care and quality outcomes. This will require a willingness to ask the tough questions, even of those sales reps that are considered a "friend." You need to find out how potentially responsive the company can be to patient needs-how close is their nearest office, is it located within the local community or several states away? Distance not only is a factor in an emergency, but also plays a role in the understanding of local weather, geography, and other factors that influence not only patient activity but also the appropriate matching of a patient with the best ambulatory oxygen equipment. Does the company offer options for oxygen therapy that includes new technologies, do they offer standardized, comprehensive patient education, are they accredited?

Table 1. Questions for DME Providers

Conclusion

Traditionally, case managers have been the gatekeepers overseeing, among other things, patient transitions from hospital to home. Successful transition now encompasses a broader definition, one that includes ensuring that patients have the postdischarge resources and support that will enable them to remain at home, free of exacerbation, for at least 30 days. Hospitalized patients are generally sedentary, passive, and dependant, but successfully discharged and supported COPD patients have the potential to transition back into active and independent people. Achieving this transition requires case mangers to partner with progressive, patient-centric DME providers that share in that goal.

References

case management; chronic obstructive pulmonary disease (COPD); durable medical equipment (DME); hospital readmission; long-term oxygen therapy (LTOT); oxygen-generating portable equipment (OGPE)