COPD (Chronic obstructive pulmonary disease) is a debilitating lung disease that, without proper care and planning, can increase a patient’s risk of being hospitalized or needing long-term ventilator use. Most hospitals have programs to treat the acute symptoms of COPD, but post-discharge programs supporting the chronic disease tend to fall short.

According to National Vital Statistics Reports, “20 percent of patients in the U.S. who are hospitalized for COPD flare-ups are readmitted within 30 days…” 

To better serve COPD patients and reduce readmissions, a group of pulmonary physicians collaborated with Nonin Medical Inc. to create the COPD STEP (Seamless Transition and Exacerbation Prevention) Plan. The goal is to give doctors, homecare providers, and patients the tools they need to better manage COPD outside of the hospital.


1. Cross-Continuum of Care

Hospitalizations are preventable through proper self-care management in conjunction with the continued support of a health care provider. Home respiratory care visits have not typically been provided and this lack of professional post-discharge follow-up care has led to readmissions. The STEP program looks to change this by implementing a comprehensive team approach with after-care to help patients manage both the acute flare-ups and chronic aspects of the disease, thus reducing readmissions.

2.  Patient-Centered Care

One of the goals of a readmission reduction program is to target and treat patients based on what nurses and respiratory therapists are seeing when inside a patients’ home. Ongoing communication and interaction with home patients can help identify and address issues in a real-time manner – be it with general self-care management or better use of their COPD equipment. Home healthcare providers can also suggest new products that a patient would not be aware of to accomplish lifestyle or routine changes.

3.  Active Lifestyle

Exercise can’t reverse COPD, but it has long been the key to successful disease management. Exercise helps COPD sufferers use oxygen better. The key is to do it, but not to overdo it. Healthcare providers can work in tandem with patients to develop an exercise program to help improve overall breathing, lower blood pressure, increase energy and improve circulation. Creating an at-home exercise plan of 30 minutes per day 5 days a week will significantly reduce the risk of rehospitalization for COPD patients.

4.  Patient Training

Unfortunately, studies have shown that when patients go home, they likely don’t remember much of the information they were provided during the discharge process. It’s imperative that a patient be given the tools to learn outside of the hospital about how to participate in their own care. Home caregivers can provide patients a checklist of responsibilities and daily activities, which are reviewed by the home caregiver and primary physician. Education, training, and reinforcement between a caregiver and patient must consistently occur in order to reduce hospital readmissions.

5.  Proper Equipment

The COPD STEP Plan spotlights the need for proper equipment and proper training on how to use it. Caregivers are tasked with addressing how patients are monitoring their condition at home and teaching them which types of inhaled medications are best for their specific needs, as well as how to properly use them. Correct usage of home oxygen products, such as those provided by AirLife, give patients the knowledge and confidence to measure their oxygen therapy and recognize the onset of an exacerbation. While equipment alone won’t reduce readmissions, adequate equipment can help patients live an active life and confidently manage their disease.

6.  Rapid Action Plan

For COPD patients undergoing an exacerbation, “time is tissue.” An exacerbation is a destructive process and can contribute to disease progression. If exacerbations are caught early and treated rapidly, hospitalization and re-hospitalization may be avoided. Healthcare teams need to train patients on how to recognize exacerbation symptoms early to be able to rapidly start a treatment plan.  Again, emphasizing a team approach and patient-centered care is critically important for the success of helping treat and prevent COPD disease progressions.

The COPD STEP Plan addresses both the acute treatment and chronic management of the disease by providing a seamless transitional care plan from hospital to home. Ultimately, when caregivers and patients follow the STEP Planand use products like AirLife at home, the hope is that more COPD patients will be able to take charge of their own health, reducing the number of hospital readmissions.

Along with implementation of the STEP plan, the following products can serve as tools to better manage COPD outside of the hospital allowing patients to live an active life and confidently manage their disease.