Projects: Innovations Grant Program

This is a two-phase project meant to identify patients with COPD who are at high risk for hospitalization and provide them with guideline recommended care in the ambulatory setting. The first phase is to develop an ED-based program that partners our Chronic Disease APNs who lead our COPD readmissions reduction program with ED providers to identify patients in the ED who require ambulatory follow-up visit in the 1-2 days post ED discharge. The second phase of the project is to identify existing primary care patients who are at high risk for admission and to provide them with ambulatory COPD consults and disease education. Our ultimate aim is to ensure patients receive high value ambulatory COPD-based care and ultimately help them avoid exacerbation that would have otherwise decreased their quality of life and possibly resulted in a hospital admission.