Reducing 30-day Hospital Readmissions for Chronic Obstructive Pulmonary Disorder (COPD) Patients by Using Mobile Health Technology and Personalized Health Coaching

Sharp HealthCare


As an extension of Sharp HealthCare’s Lean Six Sigma project focused on reducing 30-day readmissions, the mHealth COPD Transitional Care Program uses mobile health technology and health coaching to help patients with COPD exacerbation better manage their chronic condition. The program is 90% funded from grants and corporate sponsorship and uses telehealth and an evidence-based ‘care transitions’ approach to help unfunded, Medi-Cal/Center for Medicare & Medicaid Services (CMS) and unassigned Medicare Fee-for-Service (FFS) patients stay independent, well managed at home, and out of the acute care setting. The 90-day intervention focuses on improving patient self-care and confidence and is offered free of charge to patients. The intervention includes daily remote monitoring using Cardiocom’s Commander Flex, mHealth pulse oximeter, at least two home visits, and unlimited telephonic support.

Outcomes of enrolled patients diagnosed with COPD were enrolled in Sharp HealthCare’s mHealth COPD Transitional Care Program and compared with a reference group not enrolled in the mHealth program who had similar diagnoses and the same payor mix. During the 9 month recruiting period a total of 99 patients were enrolled and 86 (87%) completed the 90-day program. Thirty-six (36) patients refused enrollment; 13 patients did not complete the program for various reasons (included in the mHealth Within Group Summary Chart); 30 patients were excluded from the final analysis to ensure a balanced sample with the untreated population (information included in group summary chart); and69 patients were included in the final analysis and compared with propensity matched untreated sample (n=440). There were significant differences in care utilization between groups. The mHealth group 30-day readmission rate was 7% compared with a 19% rate for the reference group (p<.001). These results continued into the 90-day post index-discharge: the mHealth group 90-day readmission rate was 26% compared with 37% for the reference group (p=.037). These results reflect care utilization at Sharp HealthCare and do not include care sought out at non-Sharp HealthCare facilities.


Innovator: Sharp HealthCare; Corporate Partner: Cardiocom™; Community Partner: San Diego Beacon Community


Problem Addressed: The key problem addressed through the mHealth COPD Transitional Care Program is the need to reduce 30-day readmissions for underserved COPD patients. At the time the program started the readmission rate for this population was 20% (matching demographics and diagnosis). Per CMS, at least 30% of these readmissions are preventable. The potential cost avoidance for these re-admissions is over $730,000, much of which is uncompensated care due to patients’ funding sources. Solving the readmission problem is paramount for three reasons: 1) expense management, 2) hospital bed capacity, and 3) imminent changes to CMS reimbursement policies as they relate to readmissions.

Patient Population:

Admission criteria:

  • Patients who use Sharp Grossmont Hospital or physicians
  • Underserved patient (un/underfunded or funded with no medical home affiliation) – Medi-Cal or CMS, unfunded, Medicare and Medi-Cal, Medicare- FFS patients with repeat admissions
  • Adults (over 18 years of age)
  • COPD diagnosis
  • Negative drug screen (MD order) or documentation of more than one year since last substance/ETOH abuse
  • Patient is able to care for him/herself
  • Patient resides and has working address in the USA
  • Patient can be using home oxygen

Exclusion criteria:

  • Actively smoking with no plans to quit
  • Substance or ETOH abuse within 1 year of admission
  • Single diagnosis of Asthma
  • GOLD stage 4 COPD
  • End Stage COPD
  • Hospice patient
  • Active cancer diagnosis
  • Diagnosis of Pulmonary Fibrosis
  • Dialysis patient
  • Patient lives in SNF

Description of the Program The mHealth COPD Transitional Care Program at Sharp HealthCare was designed for patients with COPD who are uninsured, under insured, or unassigned (have Medicare fee-for-service with no community medical home). These patients must become better engaged in their own care. The technology used in this intervention is a mobile device, Cardiocom’s Commander Flex, that allows patients to engage in their own care and maintain their independence at home through a system of support interventions including: 90 days of daily monitoring of symptoms to ensure new learning has taken place; support from program manager and telehealth nurses for variances in symptoms; two home visits – one at the beginning of program and one at the end to ensure proper use of equipment and personalizes program to the patient; daily reminder of medication compliance; and daily resource for patient. Unlike traditional follow-up phone call only, or home care for six visits, this intervention calls for an introduction/enrollment while in the hospital, home visits (within the first week post-discharge and at 90 days), phone follow-up, and daily monitoring enabled through the technology.

The details of the program are as follows:

Assessment in hospital by program coordinator. Patients are located in the hospital system by a “COPD screening tool” (developed at Sharp HealthCare) and “Metered Dose Inhaler” report. Coordinator then screens patient for inclusion criteria and visits qualifying patients. Patient signs HIPAA and consent form. Cardiocom mobile device is ordered when patient is discharged from hospital. Written information regarding management of COPD is given to patient for review in hospital and to be reinforced during the home visit.

Evaluation of patient’s ability to manage their COPD. The Clinical COPD Questionnaire (CCQ) consists of 10 items and is divided into three domains: symptoms, functional status and mental health. The CCQ shows acceptable validity and reliability to assess post-intervention change in health status (Molen, 2003; Stallberg, 2009).

Nurse coordinator follows discharge of the patient from the hospital with a home visit timed with the arrival of the Cardiocom device.This keeps in step with the Transitions Model for management of chronic disease, as the program flows from the hospital to home. This is arranged by the nurse coordinator who the patient met in the hospital. By seeing the same health care professional, the patient remains comfortable as the patient already knows/recognizes the health care provider. The goal of the home visit is COPD management education and to ensure that the patient is proficient with use of the Cardiocom mHealth device. This can be a lengthy home visit as it is tailored to patient needs. Review includes:

  • Medication Management – Medication review, education regarding use of medications (medication reconciliation). Patient given pill box to organize medications.

  • Knowledge of Red Flags – Review signs and symptoms of COPD, when to call the doctor. This information originates in the hospital at discharge.

  • Review of Technology and Device – Review of daily symptom input from patient to Cardiocom. Positive demonstration of use of Cardiocom mHealth device.

90 days of monitoring by Cardiocom™, with use of Cardiocom Commander Flex™ mHealth Device. The daily upload of pulse oximetry and Health Check questions done by patient are reviewed by nursing staff at Cardiocom and escalated to nurse coordinator at hospital as necessary. The Health Check Score is a numeric value that characterizes a patient’s wellness. It is based on the patient’s pulse oximetry and answers to symptoms questions. Each Health Check question has been assigned a relative value from 1-10 based on symptoms severity. Patients are managed by exception; unfavorable trends, out-of-range symptom score and no transmission will trigger a phone call to the patient from the Cardiocom nurse coordinator. As necessary a case may be escalated to the hospital program coordinator and/or the patient’s physician for further follow up. This daily upload of biometric data and reinforcement of recognition of signs and symptoms of COPD exacerbation is key to patients understanding how to manage their disease. Additional home visit were made if needed and only occurred with two patients throughout the program’s duration.

Nurse coordinator available to the patient as resource throughout the program.

Home visit (2ND of 2) to facilitate graduation of program. Nurse health coach graduates patients from the program to self-care during a final home visit. This interaction covers a review of the program’s education and the patient’s progress with managing their COPD. To facilitate the transition from the mHealth program to self-care a community resource guide is provided connecting the patient to community resources such as community clinics, social services, and transportation.


Results/Program Outcomes

Sharp HealthCare’s mHealth COPD Transitional Care Program compared the outcomes of enrolled patients diagnosed with COPD with a reference group of similarly diagnosed patients with the same payor mix and baseline demographic characteristics who were not enrolled in the program. The untreated sample was propensity matched to the intervention group and outcomes adjusted for: marital status, mental health status, visit type (for index admission), ethnicity, 3M DRG severity of illness for index admission, 3M DRG risk of mortality for index admission, employment status, payor, discharge disposition, previous admission rate, and Charlson score.

Patient Enrollment: During the 11 month monitoring period a total of 99 patients were enrolled and 86 (87%) completed the 90-day program; 13 patients did not complete the program for various reasons; 36 patients were offered the program but refused enrollment; and 30 patients were excluded from the final analysis to ensure a balanced sample with the untreated population (information included in group summary chart). Sixty-nine (69) patients were included in the final analysis and compared with propensity matched untreated sample (n=440). All results are adjusted for imbalances on baseline characteristics (based on the observational nature of the evidence).

Care Utilization Outcomes

There were significant differences in care utilization between groups. At 30 days post index admission discharge, the treatment group had 93% of patients with zero readmissions compared with the untreated group which had 81% of patients with zero readmissions. The adjusted difference between groups was 12.6%, with a confidence interval of 6.1% to 19% (p<.001). mHealth 30-day readmission rate (adjusted for covariates listed above) was 7%, compared with a 19% rate for the reference group (p<.001). These results continued into the 90-day post index-discharge time frame. The treatment group had 74% of patients with zero readmissions compared with the untreated group which had 63% of patients with zero readmissions. The adjusted difference between groups was 11.4%, with a confidence interval of 6.1% to 19% (p=.037).

These results only reflect care utilization at Sharp HealthCare and not care sought out at non-Sharp HealthCare facilities.

Patient Satisfaction Outcomes

Patient satisfaction with the program was measured using the Centura Telehealth Patient Satisfaction tool. This survey was completed by patients during the graduation home visit with the nurse health coach. Possible answers were: 1. No definitely not, 2. I don't think so, 3. Maybe yes, Maybe no, 4. Yes, I think so, 5. Yes, definitely.

Patients’ overall satisfaction with the program was extremely high. Patients thought the training they received to use the device was excellent, that the remote monitoring device was easy to use, and that it helped them become more involved in their healthcare. The survey showed that patients overall felt the monitoring device was just as good as having a nurse come to the house. This was reflected in the comment section: 64% of comments specifically mentioned liking aspects of the remote monitoring device, whereas 16% of comments specifically praised the nursing aspect. Representative comments include: “knowing my oxygen helped me”; “[like] the fact that someone is watching me”; and “kept me on top of things”. Negative comments centered for the most part on instances where the device did not work properly or did not give readings as expected, and represented 21% of the negative comments (49% felt there was “nothing” negative about the device).

Quality of Life (QoL) Outcomes

The results of the Clinical COPD Questionnaire (CCQ) are as follows. The “minimal clinically important difference” (MCID) has been validated to be an average change in score of 0.4 for the total score.

There was a clinically meaningful difference in scores before and after enrollment in mHealth COPD Transitional Care Program. The difference in score was 1.93, which is well above the cut-off score of 0.4. This is interpreted as an important improvement in health status for patients after program intervention.

While the questionnaire has only validated MCID for total score, it is worth highlighting that there were large differences in average scores (1.43 and 2.08) for the separate functional domains (functional status and mental health) as well.


Context of the mHealth Program: Sharp HealthCare, a California nonprofit 501(c)(3) public benefit corporation, is the largest integrated delivery system in San Diego County, providing care to more than 785,000 individuals annually throughout the County. Sharp comprises four acute-care hospitals, three specialty hospitals, two affiliated medical groups, a health plan, two long-term care facilities, and a professional liability insurance company. Recently designated a Pioneer Accountable Care Organization (ACO), Sharp HealthCare is one of 32 ACOs across the nation that is working with CMS to pilot a program for 32,000 Medicare beneficiaries that will enhance engagement between patients and their medical providers in the coordination of care and services across all aspects of their health care needs.

As an extension of Sharp HealthCare’s Lean Six Sigma project focused on reducing 30-day readmissions, the mHealth COPD Transitional Care Program was designed to focus on leveraging technology and health coaching to help patients from Sharp Grossmont Hospital in managing their COPD. The program uses telehealth and the evidence-based ‘care transitions’ approach to help unfunded, Medi-Cal/CMS and Medicare Fee for Service (unassigned) patients stay independent and well managed at home and out of the acute care setting. This program is offered free of charge to qualifying patients and includes daily remote monitoring using an mHealth device, at least two home visits, unlimited telephonic support, and an overall focus on improving patient activation and confidence. The nurse coordinator was responsible for all clinical program components. This involved: Assessment of the patient in the hospital before discharge; Home visit within 7-10 days to ensure mHealth device properly set up and education given; 90 days of monitoring by Cardiocom; Additional home visit and/or telephone support if needed; final home visit to review follow-up plan, remove mHealth device (pulse oximeter) and administer patient satisfaction and quality of life surveys.

Getting Started With This Innovation:

  • Target Population Need to understand the clinical and demographic characteristics of the patients. Clinically, a mobile health program will be successful for a specific group. Patients who are thriving on their own may not need this intervention at the stage in their disease management. Program clinicians need to clearly understand how to meet the specific needs of late stage chronic care patients who may need a more intense intervention.

  • Health Coach (RN/LVN) Recruit looking for the following characteristics: relationship builders, advanced understanding of target diagnoses, flexible to meet patients’ needs, likeable, persistent, good listeners and ability to coach patients rather than do for them.

  • Organizational Support In addition to grant funding for additional resources for a high risk populations, organizations interested in doing this type of work also need senior and/or executive leadership to support such an innovation. Programs like this need to be considered part of an organization’s continuum of care and be an extension of the care provided rather than something separate.

Primary organizations involved in developing the program:

  • Sharp Grossmont Hospital
  • Sharp HealthCare System Services
  • Cardiocom

Secondary organizations involved:

  • Sharp Grossmont Hospital
  • Respiratory therapy department
  • Case Management/Social Services
  • Nursing staff
  • Pharmacy Patient Advocate
  • Family Health Centers, San Diego
  • Senior Resource Center
  • San Diego Beacon

The program also involved:

  • Nurse, and Lead Case Manager: Cecile Davis
  • Director of Lean Six Sigma, Sharp HealthCare: Jason Broad
  • Chief Grants & Resources Officer, Sharp HealthCare Foundation: Elizabeth Chan
  • Director of Administration, Sharp HealthCare Foundation: Susan Ressmeyer
  • Sharp Grossmont Hospitalist Champion: Dr. Kaveh Bagheri

Costs: The program’s primary cost consists of the full-time salary and benefits of a nurse coordinator. Additional expenses include the program’s operating expenses, mHealth device rental, cellular service for devices, nurse monitoring service and biostatistician resources to help with the evaluation plan and data analysis.

Sustaining and Scaling Use of the Technology:

Outcomes of the mHealth COPD Transitional Care Program pilot

  • COPD navigator:As a result of this pilot program, a COPD navigator position was established in efforts to reduce readmission rates of COPD patients at Sharp Grossmont Hospital.
    • The navigator uses the same inpatient process and tools used in the pilot program
    • hey see all patients, regardless of payor status
    • The program is inpatient only; there are no home visits or telehealth used

  • Pioneer ACO: Future phases of the care management strategy for Pioneer ACO patients include the use of mHealth technologies for the chronic care population.

Other Considerations and Lessons Learned:

  • Time invested in recruitment of staff resources is time well spent: The model requires the coordinator to do marketing, patient recruitment and patient care – not every RN wants to wear all of these hats

  • The Program cannot help every patient: Patient selection criteria has to be very specific (inclusion and exclusion criteria) and strictly adhered to for effectiveness

  • Cellular/mobile health products are required to meet needs of patients: Many patients do not have telephone land lines for wired devices and some patients need a device that they can take with them as they move from one caregiver or location to another

Adoption Barriers:

  • Balancing high demand for program resources with targeted patient selection: Program resources should stay focused on patients that this program can serve particularly when clinicians refer patients that need more resources.

  • The target patient population (under-funded/served) does not always have a primary care or specialty physician: Establish relationships with community clinics and ED on call panel physicians

  • Patients without a telephone land line were initially excluded: Need to be prepared for the additional expense of cellular-enabled devices.

  • Program duration may need to be tailored to each patient’s specific needs: Some patients may need to be enrolled in a mHealth program for longer than three months for maximum effectiveness in reducing future utilization.